Resources

Documents

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

Articles

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)

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)

Videos

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.