The President’s Council of Advisors on Science and Technology (PCAST) issued a report on Thursday that laid out recommendations to improve patient safety across the nation. Some of these included creating federal leadership positions focused on advancing patient safety and hastening research on systems of safe care.
The report asserted that patient safety is an “urgent national public health issue.” It cited data showing that one in four Medicare patients experience adverse events during their hospital stay, and that 40% of these events are caused by avoidable errors.
PCAST gave four recommendations to address this issue.
“Establishing and maintaining federal leadership for the improvement of patient safety as a national priority”
The council’s report urged the president to establish a White House-led initiative on patient safety. This effort must be designed to make healthcare safer by reducing injuries to patients and workers, and it should aim to lessen racial, social and economic disparities in patient safety, the report said.
The report also pointed out that the initiative must do a better job of comprehensively engaging relevant government agencies than previous federal efforts to improve patient safety.
Specifically, PCAST recommended that the president create a “Patient Safety Coordinator” role in the White House that is dedicated to managing patient safety improvement efforts at the federal level. The president should ensure this leader has regular communication with HHS, the Defense Department, the Justice Department and the VA so that they can keep a close eye on the progress and impact of patient safety efforts, the council said.
Ensuring that patients across the country benefit from evidence-based practices for preventing harm and addressing risks
In the report, PCAST stressed the importance of making sure that all Americans benefit from certain proven measures to reduce patient harm. Some of these measures include utilizing checklists in pre-surgery operating rooms and prioritizing situation awareness during care team transitions by sharing organized patient information, including illness severity, action plans and contingency plans.
Hospitals should be incentivized to adopt evidence-based patient safety solutions, with penalties for non-compliance and rewards for excellent performance, the report stated. Federal efforts in this area should prioritize underserved populations and safety-net hospitals.
Additionally, public reporting of adverse events or patient harm should be frequent and transparent, with the goal of timely problem-solving. The report argued that continuous improvement in reporting systems is essential for enhancing patient safety.
“Partnering with patients to reduce disparities in medical errors and adverse outcomes”
PCAST emphasized the need to involve patients, families and communities in the mission to reduce medical errors and disparities in healthcare outcomes.
The council called for a comprehensive approach involving various stakeholders to advance healthcare equity — one in which federal agencies must establish policies, budgets and training to promote diversity and inclusion in patient safety efforts. These agencies must involve experts in racism and intersectionality, healthcare workers and patients hailing from marginalized communities, the report said.
PCAST recommended that federal efforts focus on improving data collection to address racial bias and drafting a national patient safety rights charter.
“Accelerating research and deployment of practices, technologies and exemplar systems of safe care”
In its final recommendation, the council explained the urgent need to advance research and technology deployment in healthcare to minimize medical errors, injuries and disparities. This should involve the development of an extensive research agenda over a decade, focusing on human factors, safety science, computer science and health technologies to address healthcare’s most pressing and/or common safety challenges, the report stated.
Special attention should be given to harnessing emerging technologies, such as generative AI, to enhance diagnosis, prediction and treatment based on individual characteristics while ensuring fairness and data accuracy, PCAST suggested.
Federal agencies should also collaborate on an “AI for Patient Safety” program to pool best practices and develop AI technologies validated for patient safety. The DoD and VA should lead by example in implementing patient safety improvements, with regular public reporting, aiming to become exemplars of safer care within five years.
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