What is the National Patient Safety Board (NPSB)?

The NPSB is a proposed independent federal agency that would model the National Transportation Safety Board (NTSB) within health care. The NTSB is the federal agency that independently studies the accidents, mishaps, and close calls in transportation. Teams of experts from a range of disciplines then propose solutions and corrective actions to prevent future harms. The vast majority of NTSB solutions have become standard practice and widely adopted, producing exceptional levels of safety and saving lives.

In a similar way, the NPSB would support healthcare agencies in monitoring and anticipating adverse events via use of artificial intelligence, conduct studies into adverse events, create recommendations and solutions to prevent medical error, and leverage existing systems to apply knowledge gained from these studies to improve processes and systems in health care.

Why do we need an NPSB?

Prior to the COVID-19 pandemic, preventable medical error caused an estimated 250,000 deaths a year in the U.S., ranking as the 3rd leading cause of death. The pandemic has further exposed structural issues within health care that have led to additional preventable harms. The healthcare system in the U.S. has not made significant progress over the past 20 years despite ongoing efforts to improve patient safety targeted at the front lines of care. This is largely due to the lack of centralized effort to identify problems and implement solutions.

Isn’t there already an agency doing this work?

Although there are many agencies within the federal government that address issues related to health and health care (such as the Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, Health Resources and Services Administration, U.S. Food and Drug Administration, and Department of Veterans Affairs), there currently is no federal agency dedicated to independently determine why adverse events are occurring and create solutions to prevent them from happening again.

Who is leading the effort to establish an NPSB?

The NPSB Advocacy Coalition was established in February 2021 to advance the creation of an independent federal agency with the ability to study preventable medical errors and recommend solutions. The NPSB Advocacy Coalition represents providers, consumers, health plans, patient safety groups, employers and other purchasers of health care, technology companies, foundations, and universities.

How can an NPSB fix the problem of medical error?

Electronic health record systems are in broad use within health care, and these systems provide an abundance of data that can be mined for information related to how and why incidents occur. An NPSB would support healthcare agencies in monitoring and anticipating adverse events by using artificial intelligence and machine learning to identify adverse events and potential errors. The NPSB would study these events and create scalable remedies, including autonomous solutions, to prevent medical errors. By looking at medical errors from a systemic perspective, the NPSB will be able to identify where breakdowns occur within healthcare processes to keep problems from happening again.

Will an NPSB place blame for medical errors?

The NPSB will be an independent, non-punitive agency. The intent is not to place blame for mistakes but to uncover the reasons behind why mistakes occur and recommend solutions to keep the mistakes from happening again. This is the same way that the NTSB functions for transportation safety.

Will the NPSB have access to my personal health information?

The NPSB will not have access to personal health records, but rather will identify trends and vulnerabilities in healthcare delivery via de-identified data.