Why take action now?

Patient and health worker safety has been compromised for decades. Think of Coronavirus as the black light that was just turned on to reveal all the gaps in our systems that already exist.

The COVID-19 pandemic has exposed the deficiencies in healthcare, to say the least. Global leaders must act with a fierce urgency to call this safety crisis what it is: a global public health emergency.

Administrators are battling priorities, our health workers are struggling to keep themselves safe and, in turn, struggle to provide safe care. And advocating during this surge hasn’t been easy for patients to advocate for themselves or for family members to advocate for their loved ones.

Our global leaders must acknowledge that the level of medical errors occurring in healthcare is not decreasing during this time. Only bold, new ideas and solutions can move the needle on preventing patient harm and deaths. They must recognize that patient safety affects all communities and, in reality, it’s affecting people of color disproportionately more frequently.


What role does the government have in patient safety issues?

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.

We believe that there are 3 priorities that global leaders must take to address this global medical error crisis:

  1. Promoting Transparency. Be Transparent, Always. It is the best thing for everyone.
  2. Aligning payment for healthcare services with safe treatment and outcomes to motivate hospitals to invest in patient safety. Give a carrot to those that do well; give a stick to those who need motivating.
  3. Establishing a National Patient Safety Board. We encourage this in each country, globally.

Why take action on patient safety?


Promoting transparency

Currently there is a “gag rule” that prohibits the public release of hospital accreditation surveys for participation in the Medicare program, so consumers are not aware of each hospital’s record of Hospital-Acquired Conditions. By requiring hospitals to publicly report Hospital-Acquired Conditions by type and incidence rates, consumers will be empowered to choose the safest hospitals for their treatment. The legislation would require hospitals to report on the incidence rates for Hospital-Acquired Conditions and post those rates on the hospital’s publicly-accessible website.


Aligning incentives

This policy would recognize, reward and support quality improvement in healthcare, will save lives and scarce taxpayer dollars by aligning incentives. The legislation aligns Medicare reimbursement (in the US) with proven patient safety protocols. If a hospital has implemented the Best Practices established by the Secretary and Medical Errors Advisory Committee, and a medical error occurs, the hospital will be reimbursed for both the primary condition (i.e., surgery) and the subsequent medical error and its consequences. However, if a hospital has not implemented the Best Practices established by the Secretary and Medical Errors Advisory Committee and a medical error occurs, the hospital will not be reimbursed for either the primary condition or the subsequent medical error and its consequences.


Establishing National Patient Safety Board

A federal Office of Patient Safety and Health Care Quality would be established to improve patient safety and reduce medical errors across the health care system.

The Office would establish and maintain a National Patient Safety Database to receive non-identifiable patient safety work product.

The Office would award grants to facilitate the reporting, collection, and analysis of patient safety data and the development and dissemination of training guidelines and other recommendations to reduce medical errors and improve patient safety and quality of care.

The legislation would also require an on-going analysis of the patient safety data in the Database and other available data to determine performance and systems standards, tools, and best practices (including peer-review) for doctors and other health care providers necessary to prevent medical errors, improve patient safety, and increase accountability within the health care system.