Advisory council pushes Biden to adopt new federal patient safety initiatives

The President’s Council of Advisors on Science and Technology (PCAST) is pushing the White House to address the “alarmingly high rates of medical errors and patient injuries” occurring regularly across the U.S. healthcare system.

One in 4 Medicare patients experience an adverse event during hospitalization, and over 40% of those are due to errors that could be prevented, the advisory committee wrote in a Thursday letter and advisory report (PDF) to President Joe Biden.

While these harms occur “in all healthcare setting and affect all persons,” patient harms such as hospital-associated infections or surgical injuries disproportionately impact people from groups facing social marginalization and drive health disparities, PCAST wrote.

“Strong and committed federal leadership” that helps implement known safety solutions and pursues new approaches would support these issues, they wrote.

“The Biden-Harris administration can take bold action to advance health equity, improve the nation’s health and wellbeing, and avert suffering and death for hundreds of thousands of Americans each year,” the advisory council wrote in the report.

PCAST’s report outlined four major patient safety recommendations for the president to adopt:

  • Establishing and maintaining federal leadership for patient safety improvement. This would include appointing a “patient safety coordinator” who would report to the president and establishing a multidisciplinary and multicultural National Patient Safety Team.
  • Ensuring that patients receive evidence-based practices for preventing harm and addressing risks. This would include, among other efforts, incentivizing industry adoption of evidence-based safety solutions, requirements for regular public reporting and advancing health data interoperability to support tracking patient harms.
  • Partnering with patients and reducing disparities in medical errors and adverse outcomes. This would include diversifying input on patient safety performance and increasing transparency.
  • Accelerating research and the deployment of new findings. This would include the development of a National Patient Safety Research Agenda and greater use of the “revolutionary advances in information technologies.”

PCAST noted that its recommendations for patient safety will also indirectly benefit the “parallel” aim of improving safety in the healthcare workforce. Widespread patient safety improvements would also come with “substantial reductions in the total cost of healthcare in America,” the advisory council wrote.

“It should be the policy of the Biden-Harris Administration, through both federal action and public-private partnership, to immediately, dramatically, measurably and continually reduce healthcare-associated injuries to patients and workplace injuries to the healthcare workforce,” PCAST wrote.

Leah Binder, president and CEO of The Leapfrog Group, a patient safety watchdog, applauded the council for putting “a priority on one of the most devastating issues in American healthcare.”

PCAST’s recommendations directly build upon years of bipartisan presidential and congressional efforts to improve patient safety that have yielded “real progress” since work began under the George W. Bush administration, she said, “and the PCAST recommendations, if enacted, would sustain and grow the momentum for transformation.”

Of note, she highlighted two specific recommendations—to publicly report so-called “Never Events” by individual facilities and to establish a National Patient Safety Team—as efforts the group believes would have the greatest positive impact on patient safety.

“The patient safety problem has been estimated to be the third leading cause of death in the country, exceeded only by cancer and heart disease, yet there is no one individual or government agency responsible for solving it,” Binder said in a Thursday evening statement. “The patient safety problem is not impossible to solve—we know how to prevent these errors.”