Former NTSB Chairman & U.S. Healthcare Leaders Want Federal Agency for Patient Safety

Legislative action needed now to save lives, create National Patient Safety Board (NPSB)

September 9, 2021

WASHINGTON & PITTSBURGH—Sep. 9, 2021—With more than 647,000 deaths in the U.S. due to COVID-19 and 250,000 preventable deaths annually from medical error, America’s track record for patient safety is going from bad to worse.

Prior to COVID-19, medical errors were the third-leading cause of death in the United States, after heart disease and cancer.

Decentralization, absence of uniform procedures and autonomous solutions, lack of communication, inadequate access to patient and provider information, and human error … are just some of the reasons why patient safety is fundamentally and catastrophically broken, according to health industry experts.

A growing coalition of healthcare leaders from across the U.S. are now calling for legislative action to create a new independent federal agency—the National Patient Safety Board (NPSB). The NPSB would follow in part the operational model of the National Transportation Safety Board (NTSB), which has been improving and promoting transportation safety in the U.S. for more than 50 years.

Former Chairman of the NTSB Robert L. Sumwalt says, “I’ve seen the incredible influence of the National Transportation Safety Board to improve safety across transportation, and I believe there are aspects of the NTSB that can be translated to medicine, which can lead to profound effects on improving the safety of health care and consequently save lives.”

Sumwalt also pointed to the efforts of the airline industry, which is constantly monitoring operational metrics, rewarding employees for reporting negative outcomes, and openly sharing deidentified data with competitors and regulators. Such transparency, nonpunitive analysis, and independent oversight is largely absent in healthcare.

Sumwalt has joined the NPSB Policy and Advocacy Coalition coordinated by the Pittsburgh Regional Health Initiative (PRHI), which has been working to reduce medical errors and prevent medical harm for over 20 years. Adapting quality improvement techniques from other industries—like aviation, nuclear power, and automobile production—has been proven by PRHI to reduce healthcare errors, improve reliability, and create efficiencies.

“In the extended wake of the COVID-19 pandemic and with ongoing concerns about variants, it’s time to step up all efforts,” said PRHI President and CEO Karen Feinstein. “It’s now time for a National Patient Safety Board, patterned after the NTSB, and borrowing safety practices from the airline industry, to centralize and scale remedies for the preventable conditions that are killing us in ever increasing numbers.”

Critical path opportunities like eliminating wrong-site surgeries and infections acquired in hospitals; improving patient flow in emergency departments; reducing errors in hospital pathology labs; anticipating shortages of PPE; improving transitions such as acute to long-term care; and more—are uncoordinated at the federal level. There’s no single entity responsible for studying healthcare catastrophes or for sharing best practices, key learnings, or recommendations nationally.

Unless the federal government mobilizes now and creates an NPSB, the healthcare industry is destined to repeat past and present mistakes.

Call on the Biden Administration & Congress: Prioritize Patient Safety

An NPSB Policy and Advocacy Coalition has recently come together to request immediate action. Stakeholders from more than 50 leading healthcare organizations, consumer groups, and businesses are asking the White House and Congress to take the necessary legislative steps to expeditiously form the NPSB.

The coalition is composed of representatives from hospitals, health systems, insurers, patient safety groups, consumer advocates, foundations, universities, technology companies, employers, and other purchasers of healthcare. A list of coalition members can be found at npsb.org.

The public is also asked to get on board and sign up for campaign updates at npsb.org.

“The 117th United States Congress is in session through January 2023. This cannot and should not wait until the 118th … our fellow citizens need the NPSB right now,” added Feinstein. “By engaging a broad range of professionals including human factors experts, computer scientists, and system engineers, in studying medical errors, we can stop them before they happen.”

“Up Next for Patient Safety” Podcast Series Launches

To hear directly from former NTSB Chairman Robert Sumwalt and PRHI President and CEO Karen Feinstein, visit npsb.org and tune into the inaugural edition of the NPSB’s podcast series, “Up Next for Patient Safety.” This important discussion is moderated by Harry Litman, former U.S. District Attorney, law professor, and political commentator. Litman is also the producer and host of the popular podcast “Talking Feds.”

Robert L. Sumwalt
Karen Wolk Feinstein
National Patient Safety Board Logo

About the National Patient Safety Board

A proposed new independent federal agency, the National Patient Safety Board (NPSB) would model in part the National Transportation Safety Board within health care. The NPSB would improve and promote public health and welfare by monitoring and anticipating adverse events, creating recommendations and solutions to prevent medical error, and bringing lessons into practice. A coalition of leading healthcare organizations and experts are advancing the call to expeditiously form the NPSB. The public is invited to “Get on Board” with the NPSB today by staying informed and vigilant, visiting npsb.org. Like the NTSB, the NPSB will save lives.