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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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Peer Review of a Report on Strategies to
Improve Patient Safety

Paul C. Tang and Megan Kearney, Editors

Committee for a Peer Review of a Report on Strategies to Improve Patient Safety

Board on Health Care Services

Health and Medicine Division

A Consensus Study Report of

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-46280-8
International Standard Book Number-10: 0-309-46280-0
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Peer review of a report on strategies to improve patient safety. Washington, DC: The National Academies Press. https://doi.org/10.17226/26136.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

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The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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COMMITTEE FOR A PEER REVIEW OF A REPORT ON STRATEGIES TO IMPROVE PATIENT SAFETY

PAUL C. TANG (Chair), Adjunct Professor, Clinical Excellence Research Center, Department of Medicine, Stanford University School of Medicine; Physician, Palo Alto Medical Foundation

LEORA I. HORWITZ, Associate Professor, Department of Population Health and Department of Medicine, New York University Grossman School of Medicine; Director, Center for Healthcare Innovation and Delivery Science, NYU Langone Health

RAINU KAUSHAL, Senior Associate Dean for Clinical Research; Nanette Laitman Distinguished Professor and Chair, Department of Population Health Sciences, Weill Cornell Medicine; Physician-in-Chief of Population Health Sciences, NewYork-Presbyterian/Weill Cornell Medical Center

SANJAY SAINT, Chief of Medicine; Director, Veterans Affairs/University of Michigan Patient Safety Enhancement Program, VA Ann Arbor Healthcare System; George Dock Professor of Internal Medicine, University of Michigan

Study Staff

MEGAN KEARNEY, Study Director

KAREN HELSING, Senior Program Officer

TORRIE BROWN, Senior Program Assistant

SHARYL J. NASS, Senior Director, Board on Health Care Services

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

DAVID W. BATES, Brigham and Women’s Hospital

TEJAL K. GANDHI, Press Ganey Associates LLC

CHRISTOPHER P. LANDRIGAN, Harvard Medical School

ELIZABETH A. MCGLYNN, Kaiser Permanente Research

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington School of Medicine. He was responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

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Acronyms and Abbreviations

AE adverse event
AHRQ Agency for Healthcare Research and Quality
ASRS Aviation Safety Reporting System
CAUTI catheter-associated urinary tract infection
CDC Centers for Disease Control and Prevention
CLABSI central line–associated bloodstream infections
CUSP Comprehensive Unit-Based Safety Program
EHR electronic health record
FAERS FDA Adverse Event Reporting System
FDA U.S. Food and Drug Administration
GTT Global Trigger Tool
HHS U.S. Department of Health and Human Services
HIT health information technology
ICU intensive care unit
IHI Institute for Healthcare Improvement
IT information technology
MHS Making Healthcare Safer
NCPS National Center for Patient Safety
NPSD Network of Patient Safety Databases
NPSIRS National Patient Safety Incidents Reporting System
NSQIP National Surgical Quality Improvement Program
OIG Office of Inspector General
PSI patient safety indicator
PSO patient safety organization
PSQIA Patient Safety and Quality Improvement Act of 2005
PSR patient safety report
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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PSWP patient safety work product
VA U.S. Department of Veterans Affairs
VAERS Vaccine Adverse Event Reporting System
VAMC VA Medical Centers
VASQIP VA Surgical Quality Improvement Program
VHA Veterans Health Administration
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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Preface

Fifteen years ago, Congress passed the Patient Safety and Quality Improvement Act of 2005 (PSQIA), which established patient safety organizations (PSOs) and a Network of Patient Safety Databases (NPSD). The PSQIA made possible—in a legally protected and confidential manner—the collection, analysis, and use of aggregate data from multiple organizations to discover common themes in patient safety. These learnings could be used to forge systematic changes that substantially improve health care quality and safety across America. In short, the PSQIA could be the impetus to creating a nationwide learning health system. Through its enabling provisions, the PSQIA created a historic opportunity to place patient safety at the heart of health care delivery, just as the airline industry did with aviation safety.

The PSQIA required the Agency for Healthcare Research and Quality (AHRQ) to produce a report about effective strategies for reducing medical errors and increasing patient safety within 18 months of the NPSD becoming operational and to submit the draft report to the Institute of Medicine (IOM) (now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) for review. The peer-review committee closely examined the enabling PSQIA in detail and found the congressional intent clear: the purpose of creating the NPSD and PSOs that collect primary data was to “analyze national and regional statistics, including trends and patterns of health-care errors”1 to improve patient safety systematically. Consequently, the committee’s review accorded special attention to incentives and barriers to using the PSQIA-created resources—PSOs and the NPSD—to facilitate learning from aggregate data analysis.

The committee believes the country is at a relative standstill in patient safety progress. Although the original To Err Is Human report (IOM, 2000) commanded national attention more than two decades ago, the country has not achieved the level of safety in daily patient care that we have come to expect from other industries, such as when we board an airplane. Continuing on the current trajectory is not likely to produce substantial improvements in patient safety. The opportunity to demonstrably improve patient safety has never been greater as clinical data are now captured routinely in electronic health records (which was not the case in 2005), and the ability to transform those data for analysis at the population level continues to grow. Analyzing individual and aggregated population-level data makes it possible to learn what works and in what contexts. As an example, the potential to leverage PSOs to improve patient safety was highlighted in the IOM report Health IT and Patient Safety: Building Safer Systems for Better Care (IOM, 2012). In that report, the IOM identified a major barrier to preventing patient harm: the lack of aggregated patient-safety data related to health information technology (HIT). The

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1 PSQIA 2005 42 U.S.C. § 299b-22(j).

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Peer Review of a Report on Strategies to Improve Patient Safety. Washington, DC: The National Academies Press. doi: 10.17226/26136.
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report recommended that PSOs be used to collect patient-safety incidents related to HIT across organizations nationally.

We look forward to the final AHRQ report enumerating current barriers to the efforts of PSOs and the NPSD to improve patient safety along with proposed strategies for overcoming them. We hope that executing those strategies will capitalize on the opportunity to create an upward trajectory in the nation’s ability to deliver safer care. With the proper focus, the nation could substantially improve the safety of Americans.

I thank my fellow committee members for their service and commitment to submitting a comprehensive review of AHRQ’s draft report, especially on an accelerated timeline.

Paul C. Tang, Chair

Committee for a Peer Review of a Report on Strategies to Improve Patient Safety

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In response to a congressional mandate under the Patient Safety and Quality Improvement Act of 2005, the National Academies of Sciences, Engineering, and Medicine was asked to review the Agency for Healthcare Research and Quality (AHRQ) draft report Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine. The National Academies convened a committee of four subject-matter experts with experience in clinical patient safety, patient-safety research, health information technology, safety science, clinical medicine, and implementation science to conduct a peer review of the draft report. This committee had less than three months to review the AHRQ draft report and comment on additional effective strategies for improving patient safety, new evidence of effectiveness for safety strategies, potential implementation methods that were not mentioned, and any general technical corrections.

The Patient Safety and Quality Improvement Act of 2005 created valuable national resources as part of the tools needed for systemic change. The committee offers these additional strategies to improve patient safety for consideration in the revision of the AHRQ draft report to Congress.

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