National Patient Safety Board Summary (December 2023)

Report to the President: A Transformational Effort on Patient Safety | President’s Council of Advisors on Science and Technology (PCAST) (September 2023)

Establishing a National Patient Safety Board: Enhancing Medical Error Prevention (June 2023)

U.S. House Bill HR 9377 – The National Patient Safety Board Act

Do Black and White Patients Experience Similar Rates of Adverse Safety Events at the Same Hospital? | Urban Institute (July 2021)

Request for Information on Creating a National Healthcare System Action Alliance To Advance Patient Safety | Patients for Patient Safety US

Relevant Articles

Medical Mistakes Are More Likely in Women and Minorities | NBC News (January 2024)

Presidential Advisers Recommend White House Create Patient Safety Team | Axios (September 2023)

Calls Grow for National Patient Safety Board: 3 Leaders Weigh In | Becker’s Hospital Review (August 2023)

New Leapfrog Hospital Safety Grade Reveals Significant Increase in Healthcare-Associated Infections and Worsening Patient Experience During COVID-19 Pandemic | The Leapfrog Group (May 2023)

Now is not soon enough: Patients, families and the general public have much to gain from the US National Patient Safety Board Act | Patient Safety Learning Hub (April 2023)

Lessons from Health Care Leaders: Rethinking and Reinvesting in Patient Safety | NEJM Catalyst (April 2023)

The Safety of Inpatient Health Care | New England Journal of Medicine (January 2023)

House Bill Would Create National Patient Safety Board | Healthcare Innovation (December 2022)

USA: House Bill Establishes Federal Agency Dedicated to Patient Safety | Patient Safety Learning Hub (December 2022)

Barragán Introduces the National Patient Safety Board Act | U.S. Rep. Barragán (December 2022)

When Medical Error Becomes Personal, Activism Becomes Painful | Forbes (September 2022)

Patient Safety Leaders Respond to Prosecution of Medication Error | Healthcare Innovation (September 2022)

Rethinking Use of Air-Safety Principles to Reduce Fatal Hospital Errors | Health Affairs (August 2022)

Why Monkeypox Is a Repeat of the Data Mistakes Made with Covid-19 | Vox (August 2022)

A Nurse Was Just Sentenced to 3 Years of Probation for a Lethal Medical Error | Vox (May 2022)

Who killed patient safety? | Journal of Patient Safety and Risk Management (May 2022)

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 | Office of Inspector General (May 2022)

4 Actions to Reduce Medical Errors in U.S. Hospitals | Harvard Business Review (April 2022)

Health Care Safety during the Pandemic and Beyond — Building a System That Ensures Resilience | New England Journal of Medicine (February 2022)

We Need a National Patient Safety Board | Pittsburgh Post-Gazette (February 2022)

Action on Patient Safety Will Help Achieve the Health Care System We Deserve | The Hill (January 2022)

Patient Safety Often Overlooked in Mental Health Settings | AP News (November 2021)

Patient Safety Advocates Propose New Federal Agency | Becker’s Hospital Review (September 2021)

Patient Safety Advocates Want New Government Agency to Curb Patient Harms | Modern Healthcare (September 2021)

Coalition Urges Creation of National Patient Safety Board | Healthcare Innovation (September 2021)

Former NTSB Chairman & U.S. Healthcare Leaders Want Federal Agency for Patient Safety | AP News (September 2021)

Can Hospitals Learn About Safety From Airlines? | The Wall Street Journal (September 2021)

Pandemic fueled big jump in healthcare-associated infections, CDC finds | Becker’s Hospital Review (September 2021)

Holding Hospitals Accountable for Patient Safety | Harvard Business Review (August 2021)

COVID-19 Impact on HAIs in 2020 | CDC (August 2021)

New Press Ganey Report Warns That Covid-19 May Have Worsened Hospital Safety | Forbes (April 2021)

Better Care Teams: A Key Element of Better Care Plans | Health Affairs (April 2021)

Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review | The National Academy of Medicine (2021)

COVID-19 has exposed the urgent need for a National Patient Safety Authority | Modern Healthcare (September 2020)

What if there was an NTSB for Health Care? | The Atlantic (June 2020)

An Electronic Health Record–Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement | Health Affairs (November 2018)

An NTSB for Health Care | Journal of Patient Safety (March 2012)

First, Make No Mistakes | The New York Times (July 2009)


National Patient Safety Board Panel (10th Annual Patient Safety Movement Foundation Summit, June 2023)

Patient Safety Full Court Press Meetings – In 2020, the Pittsburgh Regional Health Initiative (PRHI) began in-depth work focused on the establishment of an independent, non-punitive federal agency to study and recommend solutions related to medical error. PRHI convened a think tank of experts in a series of meetings called the “Full Court Press” to begin focused efforts on how a National Patient Safety Board (previously referred to as the National Patient Safety Authority) could harness existing and emerging technologies to address the problem of medical error. The following videos contain key excerpts from presentations by experts in patient safety and technology from these Full Court Press meetings as well as an excerpt from a healthcare innovation series in 2020:  

How Would an NPSA Support Front Line Lean Safety Improvement Efforts (National Patient Safety Board Full Court Press Team Meeting, February 2021)
Ken Segel, MBA, CEO & managing director of Value Capture and the Value Capture Policy Institute, delves into how “lean” principles of truth and transparency, rigor, and technology/artificial intelligence can serve as the foundation for the efforts of a national agency focused on improving patient safety.

The National Transportation Safety Board Structure and Functions (National Patient Safety Board Full Court Press Team Meeting, January 2021)
Robert Sumwalt, former chairman of the National Transportation Safety Board, discusses how the agency addresses safety within the transportation sector and the elements of this model that could be applied to health care to identify solutions to the problem of medical error.

Advancing Patient Safety with Automation & AI: Specs and Design Features of the Autonomous Patient Safety Technology of the Future (National Patient Safety Board Full Court Press Team Meeting, November 2020)
Michael McShea, MS, MBA, health system innovation lead in the Johns Hopkins University Applied Physics Laboratory, discusses potential specs and design features of technology for automating patient safety by employing artificial intelligence.

The Specs that Exist in Pascal Metrics’ Autonomous Patient Safety Technology: Today and Tomorrow (National Patient Safety Board Full Court Press Team Meeting, November 2020)
David Classen, MD, MS, professor of medicine at the University of Utah, highlights the technology developed by Pascal Metrics that harnesses the power of existing electronic health record data to detect and predict adverse events.

Automating Patient Safety (Liftoff in Motion, September 2020)

Michael McShea, MS, MBA, health system innovation lead in the Johns Hopkins University Applied Physics Laboratory, explores the power of autonomous technologies to improve quality of care and reduce medical error and how it can integrate with current and new systems.