Harm to patients and healthcare workers across the continuum of care can be dramatically reduced using the power of available technologies deployed in other complex, high risk industries. They include advanced analytics, artificial intelligence (AI), and machine learning to mine large, existing data sets to anticipate and avoid harm through automated corrective action. The unsatisfactory progress on reducing preventable medical errors, and the deaths resulting from a pandemic for which we were disturbingly unprepared, underline the critical need for a new and bold safety strategy—one that prevents harm before it occurs and responds vigorously when a crisis emerges.
The Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative and a growing coalition of partners propose a National Patient Safety Authority (NPSA), using the well-established and successful National Transportation Safety Board (NTSB) as a model. The NTSB is structured as an independent agency that investigates accidents and proposes recommendations and solutions to prevent the adverse events from re-occurring. The NTSB’s solutions often rely on autonomous safety technologies, such as airbags, autonomous slack adjusters, anti-collision equipment, autopilot features, fail-safe thrust reversers, automatic shutoff valves, and autonomous internal inspections and correction devices for pipelines.
The NPSA, like the NTSB, would guarantee a data-driven, non-punitive, collaborative approach to protecting patients and providers. The NPSA would exist as an independent agency at the federal level and interface with HHS agencies (e.g., CMS, ONC, AHRQ, CDC, FDA, NIH, and ONC) similar to how the NTSB interfaces with the Department of Transportation (DOT) and its Federal Aviation Administration (FAA). At its core, the NPSA would mine big data from EHRs to monitor and anticipate medical errors with AI and machine learning technology, investigate major safety events with NTSB-like “Go Teams,” and create recommendations, including autonomous solutions, to prevent medical errors. While saving lives, an NPSA would reduce the cost of care (related to litigation, waste, and inefficiency) and alleviate worker burnout by centralizing data collection, enabling autonomous safety measurement, real-time safety monitoring, prediction, and corrective action.
It is time to extend fail-safe technologies to health care, where people can then seek medical care without the threat of unanticipated and preventable adverse events. The key ingredients exist. Our nation’s $30 billion federal investment in Electronic Health Records (EHRs) has unlocked healthcare data and AI technology is available to convert the data into intelligence. Automation is also turning appropriate actions over to the computer to create safe and assured operations and team with providers and patients, accomplishing human-specified goals and decisions with trust.
The nation has the capability to detect the conditions that precede error, to identify critical risk factors, and to act in time to reduce pain and suffering. Does it have the political will?
If you are interested in joining the effort to advance the NPSA, please contact us at firstname.lastname@example.org.
Download a summary of the proposed National Patient Safety Authority here.
Better Care Teams: A Key Element Of Better Care Plans | Health Affairs (April 2021)
New Press Ganey Report Warns That Covid-19 May Have Worsened Hospital Safety | Forbes (April 2021)
2018 EHRs and Patient Safety Surveillance | Health Affairs (November 2018)
COVID-19 has exposed the urgent need for a National Patient Safety Authority | Modern Healthcare (September 2020)
There’s a better way to protect patients | Pittsburgh Business Times (March 2021)
What if there was an NTSB for Health Care? | The Atlantic (June 2020)
The National Transportation Safety Board Structure and Functions
Honorable Robert Sumwalt, Chairman, National Transportation Safety Board. January 25, 2021. NPSA Full Court Press Meeting. Recording here.
Automating Patient Safety
Michael McShea, MS, MBA, Health System Innovation Lead, Johns Hopkins University Applied Physics Laboratory. September 2020. Liftoff in Motion. Recording here.
Advancing Patient Safety with Automation & AI: Specs and Design Features of the Autonomous Patient Safety Technology of the Future
Michael McShea, MS, MBA, Health System Innovation Lead, Johns Hopkins University Applied Physics Laboratory. November 16, 2020. NPSA Full Court Press Team Meeting. Recording here.
The Specs that Exist in Pascal Metrics’ Autonomous Patient Safety Technology: Today and Tomorrow
David Classen, MD, MS, Professor of Medicine, University of Utah. November 16, 2020. NPSA Full Court Press Team Meeting. Recording here.
How Would and NPSA Support Front Line Lean Safety Improvement Efforts
Ken Segel, MBA, CEO & Managing Director, Value Capture / Value Capture Policy Institute. February 25, 2021. NPSA Full Court Press Team Meeting. Recording here.