Stand Up For Change
The Patient Safety Movement is a “big tent” organization that invites the contributions of the broadest spectrum of policy professionals: patient advocates, public officials, public health professionals, and healthcare reformers. The Patient Safety Movement welcomes you all to the fight.
Overall, the Healthcare Crisis in America at present is largely recognized now as being particularly a consequence of waste, fraud, and abuse. Globally, the story isn’t much different.
By learning about more friends and family affected, the public is rapidly becoming more outraged by this realization. And we, through this Patient Safety Movement, are serving the public by addressing perhaps the most socially egregious aspect of waste, an apparent disregard for the safety and well-being of patients in hospitals that can be mitigated by the very straightforward processes, Actionable Patient Safety Solutions™ (APSS™), we recommend.
It’s Time for a Patient Safety Moonshot Goal
We also believe that NOW is the time for people who have experienced unsafe care and concerned citizens to rise up and educate themselves on what they can do to make care safer, and create a public Movement to drive our Patient Safety Moonshot™ forward.
The Costs of Preventable Deaths
From both human and financial perspectives, the cost of preventable patient harm and death is staggering.
In the United States:
- 200,000 deaths per year affect millions of family members, friends, and colleagues
- Medical errors are the 3rd leading cause of death behind heart disease and cancer
- The economic impact of medical errors is estimated to be between $19.5 and $958B per year
- Medical errors are the 14th leading cause of death.
- Preventable in-hospital deaths kill more people than Tuberculosis (TB), Malaria and HIV, combined.
But, as with any challenge of this magnitude, the opportunity to achieve positive change is equally vast.
Helpful Introductory Resources
We invite you to review our Challenges & Solutions. You’ll find the latest patient safety problems that hospitals and healthcare organizations are facing as well as solutions built by a multidisciplinary group of patient safety experts and patients who volunteer their time updating them annually.
Although it’s a painful experience, we encourage you to read our Patient Stories. If you need any additional evidence that preventable death is a major public health issue, you’ll find it there.
Finally, we invite you to attend the World Patient Safety, Science & Technology Summit. Attending the Summit, which has emerged as the preeminent patient safety conference in the nation, is an excellent way for you to get immersed––quickly and deeply––in the Movement. You are sure to come away with new policy directions to explore.
Public Policy Resources
We’ve compiled information about what Government and Elected Officials have supported our Movement and patient safety-related initiatives. We also share several Reports and Resources that may be helpful. And lastly, you’ll find what External Legislation the Patient Safety Movement Foundation has supported.
Is there a global or national plan to reduce medical errors?
The World Health Organization finalized the Global Patient Safety Action Plan (2021-2030) in May of 2021 when the World Health Assembly approved the proposal. This action plan is publicly accessible here. Please share this with your elected officials, no matter where you are in the world. Our healthcare leaders in government now have a detailed action plan they can have their Secretary or Minister of Health follow.
What role does the government play to advance patient safety?
In the United States, the federal government is involved in patient safety both as a regulator and a payer. As a regulator, government agencies like the Food and Drug Administration (FDA) serve an important role to ensure safety standards for medicines and medical devices. As a payer, the Centers for Medicare and Medicaid Services (CMS) provides healthcare benefits for over 90 million people by reimbursing hospitals, doctors, and other clinicians for the care they deliver to patients. Through these dual functions, the government has considerable influence on the standards for patient safety across the country.
What can you do to improve how the government protects patients from preventable harm?
Congress creates laws, provides funding for federal agencies, and conducts oversight of how laws are being administered by the government. Your elected representatives serve as your voice in this process and need to hear from you to make sure they are aware of important issues like patient safety. Share your personal experiences with them, explain your concerns, and offer possible solutions for them to consider. Your state elected officials also have an important role in making laws about health insurance and the licensing of medical facilities and healthcare providers.
Doesn’t the government already have laws and rules about patient safety? Why aren’t these laws helping reduce the number of preventable medical errors?
There are many laws and regulations in place that aim to reduce medical errors, make patient safety a priority, and provide transparency about medical errors and preventable harm. However, many of these laws and rules simply are not working to reduce the rate of medical errors. It is time to reevaluate some of these laws and make necessary changes. Some of the PSMF policy proposals are outlined below that focus on reforming and improving the healthcare delivery system. Government must use its considerable influence as a regulator and a payer to drive changes.
Dr. Death, a new series on Peacock, shares the story of Dr. Christopher Duntsch, a neurosurgeon who was nicknamed “Dr. Death,”after being convicted of maiming dozens of patients and killing two in Texas. The Dr. Death case is rare. When harm occurs in a hospital, it is mostly systemic issues that relate back to the health system; it’s very rare for a health worker to inflict harm. But, Dr. Duntsch wasn’t the first and won’t be the last.
We believe that it’s important to highlight this case as an example to learn from so that we can achieve ZERO preventable patient harm and death. The reason we’re addressing some of the issues that the Dr. Death series highlights is to raise awareness about some of the ways that Dr. Duntsch could have been caught earlier, if the system had been working properly. Below we share the role of the National Practitioner Data Bank (NPDB) and State Medical Boards (SMB) which did not capture Dr. Duntsch’s malfeasance. The problem in this case was that the administrators and health workers working alongside Dr. Duntsch did not report to the NPDB. The State Medical Board of Texas, however, did fail at doing its job to protect the public. Instead the Texas Medical Board protected Dr. Duntsch, a neurosurgeon who brought in a considerable amount of money into the health system. It ignored patients who were trying to seek justice. We also discuss how we, here at the Patient Safety Movement Foundation, are driving a culture of safe and reliable care.
What is the National Practitioner Data Bank?
The National Practitioner Data Bank (NPDB) is operated by the U.S. Department of Health and Human Services. The NPDB is a confidential database that contains information submitted by hospitals, healthcare organizations and state licensing boards (including State Medical Boards) about physicians and other health care practitioners. The type of information that is found in the NPDB includes restrictions placed on clinical privileges for individual practitioners, actions taken against physicians’ licenses, as well as medical malpractice payments, among other variables.
Who Can Access the National Practitioner Data Bank’s Data?
Individual practitioner data is not publicly available and is restricted to “authorized users.” These authorized users include hospitals and healthcare organizations, health plans, state licensing boards, and medical malpractice payers and these entities use information from the NPDB to consider a practitioner’s application for hospital privileges or a state medical license. Other entities that may apply to query the database include professional societies as well as agencies or contractors that are administering Federal or State healthcare programs.
A Public Use Database containing deidentified statistical data is open to members of the public. This data is often used by researchers for statistical analysis but not very helpful to patients. Practitioners themselves are able to access their own records.
Why the Lack of Transparency?
Powerful associations and professional bodies that protect practitioners have lobbied to keep this information out of the public eye in the interest of individual practitioners.
How Culture Fits Into This Lack of Transparency
Helping to build a culture of safety in healthcare organizations, with open and honest reporting practices and a focus on continuous improvement, is happening slowly but surely in many healthcare facilities and health systems. If every organization tracked errors and near misses effectively, and eliminated the naming, shaming and blaming of individual practitioners, then there would be little need to report to a national data bank. However there needs to be accountability when established safe practices are not followed. So this is an alternative that the Patient Safety Movement Foundation is pushing forward – a model called Communication and Optimal Resolution (CANDOR). You can read more about our approach which is built on a foundation for a safe and reliable healthcare system.
Background on State Medical and Nursing Boards
State Medical Boards (SMBs) and State Nursing Boards (SNBs) are government agencies but the functions of them vary by state. Since these Boards are appointed by the state’s governor the funding, functions and the priorities of the boards are highly subjective. In general, the Boards oversee the licensing of medical doctors and nurses, investigate complaints, discipline health care providers who violate the medical practice act and refer them for evaluation and rehab when appropriate.
One of the major challenges of each state having different functions and priorities is that if a health care provider is disciplined in one state for one specific reason, or if a health care provider’s license is revoked in one state, they may well be able to move to another state to practice without breaking any of that state’s laws, slipping under the radar if the hospital in the new state doesn’t query the NPDB – as they are required to.
The Link between State Medical and Nursing Boards to the National Physician Data Bank
While hospitals, healthcare organizations and SMBs are required to report into and make inquiries into the NPDB to monitor and track physicians, the adherence is another story. The example above where a physician’s license is revoked in Alabama and moves to Florida relies on the hospital where the physician is seeking privileges to do their due diligence before they hire that doctor.
Public Information from State Medical Board Investigations
The public cannot see the outcome of any complaints to a state medical board unless a physician has been disciplined. However, when there has been a settlement sometimes all the details are concealed. One example is listed below for the state of California – where you can go to the Breeze License Verification page and query the name or license number of a medical doctor. Since most complaints are dismissed without disciplinary action, it is possible for a provider to have numerous complaints with no public record.
Conflicts of Interest
Conflict of interests of board members is another issue that affects the ability of SMBs to remain impartial when deciding whether to discipline doctors. The boards are often composed of physicians and other healthcare workers or industry professionals. This can create a conflict of interest when those boards are asked to investigate and discipline their peers, or stakeholders who they work with if they are from the healthcare industry.
Lack of Transparency
There’s no requirement in many states to make any information from the SMB meetings public, which means that the results of investigations and the decisions may be kept in the dark.