Full Court Press Convenes National Data & Patient Safety Experts

Patient Safety Full Court Press Team members gathered to discuss opportunities in data analytics and human factors engineering.

On June 17, the Patient Safety Full Court Press Team met to discuss data analytics and human factors engineering opportunities for the proposed National Patient Safety Board (NPSB), hearing from several national experts. The presentations and ensuing conversation demonstrated clear opportunities for an NPSB to leverage existing data and other successful models of monitoring, as well as innovative engineering strategies, to make an impact on patient safety.

Patient Safety Full Court Press Team and Pittsburgh Regional Health Initiative Board Co-Chair Steven Irwin, JD opened the meeting and gave an update on the NPSB Policy and Advocacy Coalition's work. Several new groups have joined the coalition, and the proposal is garnering attention in Washington, D.C. The Coalition is continuing to focus on securing co-sponsors.

Paul Tang, MD, MS, Adjunct Professor at the Stanford Clinical Excellence Research Center and a member of the Health and Medicine Division Committee of the National Academy of Medicine (NAM), spoke on the NAM Committee's review of AHRQ's draft report on patient safety. He commented on how the country is at a relative standstill in patient safety progress. Dr. Tang discussed suggested strategies to enhance the surveillance of patient safety data while reducing the burden on individuals and organizations to collect and manage the data. Technology, including artificial intelligence, and automated data transmission from electronic health records could help to accomplish these goals, Dr. Tang noted. A Pittsburgher, Dr. Tang previously worked as the Vice President and Chief Health Transformation Officer for IBM Watson Health.

Robert Ball, MD, MPH, ScM, Deputy Director of the Office of Surveillance and Epidemiology, Center for Biologics and Evaluation Research at the Food and Drug Administration (FDA) presented information on the FDA's Sentinel System, which monitors medical product safety. In 2019, Dr. Ball shared, the FDA established a new Sentinel innovation center, and actively works with existing data to prevent problems with drugs and medical devices.

Wayne Loschen, MS, Software Engineer/Project Manager at the Johns Hopkins University Applied Physics Laboratory (JHU APL) spoke on the laboratory's ESSENCE disease surveillance system, which governments and health organizations can use to process large amounts of health data and detect potential outbreaks of disease. ESSENCE has been used to surveil many diseases, including Zika virus, Ebola, influenza, and COVID-19, and to monitor mass gatherings and emergencies/natural disasters. Through the National Syndromic Surveillance Program, 71% of U.S. emergency departments currently contribute emergency department data, which the CDC manages with ESSENCE.

Jonathan Gleason, MD, Executive Vice President and James D. and Mary Jo Danella Chief Quality Officer at Jefferson Health shared how human factors engineering could be used to reduce medical error. Dr. Gleason described human factors engineering as "socio-technical" work, where humans and machines are intimately partnered to prevent errors. Rather than using education and behavior change to prevent errors, human factors engineering modifies equipment and systems to better fit human needs while increasing safety. This has already been applied in the aviation industry and has potential for wider application in health care.

The Patient Safety Full Court Press Team will next meet in July to discuss further steps for building and advancing the NPSB proposal.