President’s Group on Patient Safety Publishes Recommendations
The President’s Council of Advisors on Science and Technology (PCAST) recently released its findings and recommendations on patient safety in a report that outlines how “patient safety is an urgent national public health issue.”
“Medicare patients suffer an adverse event in one out of four hospitalizations, and one-third of those adverse events are serious, including catastrophic outcomes,” the council noted. “[A]dverse outcomes disproportionately impact people from groups historically experiencing social marginalization, widening gaps in healthcare disparities.”1
The report may be a good start, but it does not provide much in the way of concrete solutions, says Paul F. Schmeltzer, JD, senior attorney with Clark Hill in Los Angeles.
“Elements of the report’s recommendations have good bones, but there’s really hardly any meat on them,” Schmeltzer notes. “Establishing the federal leadership for improving patient safety as a national priority is a great initiative to start. But really, the recommendations are a bit scant on the details of how that’s going to be done.”
CMS May Act
Schmeltzer believes the impact from the report will be minimal. The council’s report does not sufficiently address the technological changes in the healthcare industry. “The implementation and adoption of all that technology has been so rapid that I certainly don’t think that having a 10-year plan in this sort of laissez faire attitude is recommended at this juncture, especially if our concern is patient safety and more favorable patient outcomes,” Schmeltzer says.
The most likely result from the report is to support CMS acting on patient safety, says Robert Andrews, JD, CEO of Health Transformation Alliance in Washington, DC, which oversees the strategic direction of more than 50 major corporations to fix the U.S. healthcare system. Andrews served as a member of the United States House of Representatives for nearly 24 years.
CMS may attach some of those recommendations to Medicare and Medicaid spending. “Because of the division in the Congress, it’s very unlikely you’re going to find statutes passing. It’s just not very likely because healthcare is a divisive issue,” Andrews explains. “But CMS is kind of regulatory authority 101. It’s where most of the power is, with all the money spent there. I think you’ll find some of the recommendations taken up by CMS as a way to try to improve Medicare and Medicaid.”
The report outlines several positive steps forward in improving patient safety, says Deborah Hunt, PhD, RN, Dr. Betty L. Forest dean of the College of Nursing and Public Health at Adelphi University in Garden City, NY. Hunt says the recommendation to create a patient safety coordinator role in the White House is good, although she doubts one person could handle such a big issue. It may be necessary to employ state coordinators.
“I think the more important factor is, what is going to make a big difference?” Hunt says. “You can go to every single healthcare setting and everyone’s going to have safety standards. But how do we get them to be followed 100% of the time? How do we really develop that culture of safety?”
The report identifies several key issues implicated in the U.S. medical error problem but does not address the nearly identical, stalled effort that was made to reform patient safety years prior — the National Medical Error Disclosure and Compensation (MEDiC) Act, says Henry Norwood, JD, an attorney with Kaufman Dolowich in San Francisco.
Patients and providers are necessary stakeholders in any realistic effort to improve patient safety nationwide. Unfortunately, the report does not make recommendations regarding provider liability, a key issue that would prevent willing disclosure of medical errors, Norwood notes.
Because many providers are required to disclose medical errors by state statutes and professional rules, the report recommendations are unlikely to have much effect on providers or organizations.
“While the report spotlights important factors in the medical error problem, which deserve national recognition, the lack of clear steps for the executive office to take and exclusion of medical malpractice reform from the recommendations suggest the report will face similar opposition from stakeholders as the MEDiC Act and have little impact on the medical error problem,” Norwood concludes.
- President’s Council of Advisors on Science and Technology. Report to the President: A Transformational Effort on Patient Safety. September 2023.
- Robert Andrews, JD, CEO, Health Transformation Alliance, Washington, DC. Email: [email protected].
- Deborah Hunt, PhD, RN, Dr. Betty L. Forest Dean, College of Nursing and Public Health, Adelphi University, Garden City, NY. Phone: (516) 833-8181. Email: [email protected].
- Henry Norwood, JD, Kaufman Dolowich, San Francisco. Phone: (628) 219-9814. Email: [email protected].
- Paul F. Schmeltzer, JD, Clark Hill, Los Angeles. Phone: (213) 417-5163. Email: [email protected].
The President’s Council of Advisors on Science and Technology recently released its findings and recommendations on patient safety in a report that outlines how “patient safety is an urgent national public health issue.”
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