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Advocates campaign for National Patient Safety Board.


Over the past several weeks my brilliant colleagues in the Consumers Union Safe Patient Project and I wrote the following letter to our Congressional members of Healthcare committees and to President Obama.  About 3 dozen of us from all over the US have signed this letter in hopes that our representatives at the Federal level will propose, sponsor and support  a National Patient Safety Board.  Some of us have also forwarded this letter and a second more personal letter  to our State and local lawmakers and others who influence healthcare policy.  A Patient Safety Board could also accomplish a lot on a State level.

This campaign is a concerted effort of Patient Safety advocates in many States who have worked as individuals, and as part of our Consumers Union network to improve  the quality and safety of healthcare and to eliminate Healthcare harm.  Healthcare harm is the third leading cause of death in the US, and kills as many as 440,000 people in the US every year.  It is time for us to move our campaign forward.  None of us wants anyone else to witness or suffer through what we have.

Here is the group letter was sent to lawmakers on both the State and Federal levels.


July 10, 2014

We are writing as consumer advocates for patient safety to express our grave concerns about the quality and safety of the U.S. healthcare system. We ask you to act urgently in response to this crisis to protect patients and the public safety. In particular, we are requesting that Congress establish a committee focused on patient safety and create a National Patient Safety Board.


As a brief background, many in our group are patients and family members of patients who have been directly impacted by preventable medical errors or health care-acquired infections.  Others are physicians or former health care officials who are appalled that effective steps to eliminate medical errors and health care-acquired infections have not been implemented. Reports show that one out of four hospital patients is presently harmed by adverse events.[1],[2] At the national level, it is estimated that as many as 440,000 patients die each year from preventable medical harm,[3] including 75,000 deaths from hospital-acquired infections alone[4]. Medical harm is now the third leading cause of death in the U.S.


According to a recent Commonwealth Fund report, “Mirror, Mirror on the Wall,”[5] the U.S. ranks at the bottom among 11 advanced countries both on aggregate score and many individual health care measures such as outcomes, quality, and efficiency. This last-place ranking should not be acceptable to our federal policy makers, especially when the U.S. spends almost twice as much money per capita on health care as the average of the other 10 nations.


We recognize that there have been many state and federal efforts aimed to improve the quality and safety of care. However, despite these efforts, there has been little improvement in overall patient safety and lives saved. Many patients are still being harmed every day in our hospitals as a result of preventable medical errors and hospital-acquired infections.


From our personal and family tragedies, we have learned that the damage done due to preventable medical errors does not just stop at the senseless injury or loss of a precious human life. There are life-long physical, social, and financial impacts on injured patients and their families, including immeasurable pain, suffering, and impoverishment of formerly productive members of society. This is aside from the staggering financial burden that medical harm imposes on all taxpayers, contributing significant costs to federal and employee assistance programs. The average cost to remediate a medical error has been estimated at approximately $13,000, resulting in an additional total cost of $19.5 billion.  The total cost can reach nearly $1 trillion per year due to the loss of productivity of those harmed or the family members who must stop working in order to care for them.[6]


Preventable medical harm has become a major public health hazard and a drain on our national resources.  Safeguarding the public from these risks should be a first priority and not be delayed any longer. We believe that a Congressional committee that would focus solely on safety in healthcare, in the same way that Congress regulates safety in the fields of aviation, ground transportation, nuclear power, and the workplace, should be urgently considered. Congress currently has safety oversight over each of these other sectors, but not over healthcare safety, yet the U.S. healthcare system kills far more people than all the deaths associated with transportation, products, nuclear power, and workplace combined. The establishment of a Congressional Patient Safety Committee would be an enormous asset in helping the nation to focus its efforts on regulating healthcare safety in the U.S.  We believe Congress has the potential to save many lives with such an action.


We write to urge you to sponsor the establishment of a Congressional Committee on Patient Safety. We also urge the Congress to create a National Patient Safety Board, which would function much like the National Transportation Safety Board (NTSB).[7] Harm to patients should be investigated just as airplane crashes are presently investigated. The NTSB, FAA and Congressional oversight have made the airline industry in the US the safest in the world.  We should strive to make US healthcare the safest in the world.


After witnessing and suffering the consequence of unsafe medical care, we want to keep these tragedies from happening to other mothers, fathers, wives, husbands, sisters, brothers, and their children.


We look forward to hearing your response and would be happy to answer any questions you have.


Thank you for your attention to this pressing matter.



33 Patient Safety advocate’s signed.




[1] Department of Health and Human Services, Office of Inspector General, “Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries”, 2010, OEI-06-09-00090.

[2]  Christopher et al., “Temporal Trends in Rates of Patient Harm Resulting from Medical Care”, N Engl J Med., 363, 2010, DOI: 10.1056/NEJMsa1004404.

[3] James, T. J., A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care, J Patient Saf., 9(3), 2013, doi: 10.1097/PTS.0b013e3182948a69.

[4]  Magill SS, Edwards JR, Bamberg W, et al. Multistate Point-Prevalence Survey of Health Care–Associated Infections. N Engl J Med 2014;370:1198-208.

[5] Davis, et al., Mirror, Mirror on the Wall, How the Performance of the U.S. Health Care System Compares Internationally, http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf

[6]  The Economic Measurement of Medical Error, Society of Actuaries, 2010

[7] Joe Carlson, Cleveland Clinic cases highlight flaws in safety oversight, 2014, http://www.modernhealthcare.com/article/20140607/MAGAZINE/306079939

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