Why now?

Patient and health worker safety has been compromised for decades. Think of COVID-19 as the black light that was turned on to reveal all the gaps in our systems that already existed.

The COVID-19 pandemic exposed deficiencies in healthcare, to say the least. Global leaders must now 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 the pandemic was a major challenge for patients to advocate for themselves and 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.


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 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?

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. We have sample materials here that you can use to write to your elected officials. In the US, 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.

Why take action on patient safety?

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. 

The Three Key Concepts

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

  1. Driving Safety Data Transparency.
  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 Region-appropriate Oversight. We encourage this in each country, globally.

Driving Safety Data Transparency

Current patient death and injury data are only estimates compiled by researchers. We don’t really know how many people are affected each year. This is because we don’t have an accurate method for measurement and we lack a national and global commitment to standardize metrics. There is no requirement that the frequency and severity of all medical errors, or the resulting patient outcomes, are reported to the public or even to public health authorities.

Care and patient procedures (e.g. hip and knee replacements) are rapidly moving out of the hospital and into ambulatory settings where there is no transparency in place to drive the quality and safety of outcomes, reporting or incentives. The same is true for children’s hospitals and very small hospitals (critical access hospitals) as well. The public has very little insight into which of these facilities are safe.

Death certificates mask the problems by not including “preventable medical error” as either a secondary or primary cause of death. They typically state the diagnosis or underlying condition, such as “myocardial infarction (heart attack)” or “sepsis,” even when treatment or diagnostic failures were the actual cause. Additionally, the death certificate isn’t always completed by someone who has cared for the patient and therefore can sometimes be incorrect and very difficult to change after it is issued.

And, in addition to this gap in surveillance, transparency is impeded by fear. Organizations and clinicians are often fearful to be transparent with patients and families about medical errors that have occurred due to fear of litigation, blame or loss of reputation. A focus on high reliability systems instead of individual blame and transparency of all patient harm and death is key to improving transparency. Programs like CANDOR (Communication and Optimal Resolution), supported by the Agency for Healthcare Research and Quality (AHRQ), when properly implemented, also drive transparency in addition to improving patient outcomes, saving money, and fostering continuous learning. Zero harm is not achievable without transparency as the first step.


Aligning Incentives

There is misalignment between the goals of healthcare organizations, clinicians, payors, and patients. Our current care delivery model was designed to pay for care for existing disease, not to promote wellness and prevent illness. Healthcare organizations and clinicians are generally paid according to the volume of hospitalizations, visits, and procedures completed, rather than by quality and safety-related patient outcomes. This incentivizes unnecessary care or overtreatment, which increases both the cost and risk of harm. In addition, care and procedures (e.g. hip and knee replacements) are rapidly moving to ambulatory settings where the payment policy necessary to drive the quality and safety of outcomes is especially lacking. While there has been much attention to patient safety in the last 20 years and some success around specific risks like central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI), these are just the tip of the iceberg of preventable harm. Despite the best intentions of those on the frontline, we will never reach zero harm in healthcare until financial incentives for healthcare organizations are aligned with the goal of systemic prevention of all-cause harm in all care settings.


Establishing Region-appropriate Regulatory Oversight, Globally

Research and discussion about the need for effective patient safety oversight and legislation have increased in many countries over the past two decades as patients, providers and the press have driven awareness of the alarming risk of unsafe care to public health.  Yet few countries have comprehensive programs for reporting, investigation, and collective learning at national or regional levels. A regulatory approach is needed in each country similar to the agencies and boards squarely focused on safety in the aviation and transportation industries, to ensure that provider organizations truly have safety processes and training programs in place. This type of oversight also helps to support a transparent culture of safety in healthcare that enables provider organizations to more rapidly identify risks, learn from each other’s experiences and spread innovative solutions.

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Submit Your Support

Join a Large Network of Passionate Individuals

By submitting your support, you are stepping up to take action individually but you will also provide the Patient Safety Movement Foundation with helpful information so that we can know who supports these initiatives. This is your opportunity to be heard. Your support will help PSMF advocate for change by showing that these issues are supported by the people – current and future patients who want to improve patient safety.

Get Access to Briefing Documents

We will also share briefing documents with you based on the issues you marked that you support.

Receive a Guide to Write Effective Letters to Your Local Elected Officials

In addition to briefing materials, we will also provide you with tools for you to write a letter to your local assemblyperson, senator, representative, and other government leaders who have the power to improve patient safety.

Click below to understand how to raise your voice in support. If you have questions please contact policy@patientsafetymovement.org