Becker's Clinical Quality & Infection Control

16 QUALITY IMPROVEMENT & MEASUREMENT Calls grow for national patient safety board: 3 leaders weigh in By Ashleigh Hollowell I ncreasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modeled off the National Transportation Safety Board. e group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organizations. "e goal of the National Patient Safety Board is to prevent and reduce patient safety events in healthcare settings," the document reads. "As a non-punitive, collaborative, independent agency, the NPSB is modeled aer the National Transportation Safety Board and the Commercial Aviation Safety Team. e NPSB, like the NTSB and CAST, would guarantee a data-driven, non-punitive, collaborative approach to preventing and reducing patient safety events in healthcare settings. Its goal is to dramatically improve the understanding of major sources of harm and bring stakeholders together to create solutions." e bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection. ree patient safety professionals shared their takes with Becker's. Editor's note: Responses have been lightly edited for clarity and length. Question: As a medical expert, how do you believe the establishment of a national patient safety board in the U.S. would impact the overall quality of healthcare? Deborah Rhodes, MD. Enterprise Chief Quality Officer at Yale Medicine and Northeast Medical Group: Progress in healthcare quality and safety has not kept pace with other safety-focused industries, such as the aviation industry. Some of this has to do with the relative complexity of the underlying systems: Standard work is more feasible in the airline industry because airplanes are far less variable than patients! However, healthcare still has much to learn from advances in aviation safety: In the two decades since the publication of the IOM report, commercial aviation fatalities in the U.S. have decreased by 95 percent. One key factor in this success is the National Transportation Safety Board, an independent federal agency. e Board does not have the Antibiotic resistance is more common in infections with mixed strains, study finds By Ashleigh Hollowell A ntibiotic resistance may be even more likely for patients infected with mixed strain pathogens, according to a report published July 12 in Nature. Researchers screened patients for mixed strain pathogen infections as part of a clinical trial and found that "at least 1/3 of patients are colonized by multiple Pseudomonas strains, and that resistance evolves rapidly in these patients due to selection for pre-existing resistant strains." They suggest additional investigation to fully understand this link but suggest that taking measurements on the diversity of a pathogen population could allow experts to "more accurately predict the likelihood of treatment failure at the level of individual patients," the study authors wrote. n out there," he said. "So it certainly makes me concerned knowing that fungi are hardy, adaptable, they are the most similar organism to humans to human cells, which makes them hard to kill and hard to identify because they're similar to our own bodies and therefore drugs that kill fungi kill human cells, potentially. So we will have to find specific targets for new antifungal drugs." Where physicians come in While there may not be the tools to-date to track or diagnostically test all known — or unknown and emerging — fungal pathogens yet, Dr. Chiller said further education about fungal infections in medical schools, within hospital environments and encouraging physicians to "ink fungus" when considering diagnoses can help in the meantime. "Right now if you don't have a test you don't know that you're dealing with this sort of as a clinical syndrome. e fungal clinical illnesses look like every other illness and so it can be really hard to distinguish them…" he said. "ey'll have to consider if a diagnosis could be a fungal infection. What we can do today is start thinking about fungus more when it comes to our patients and make the diagnosis if we think it's a possibility." e CDC's mycotic diseases division is also working toward improvements in testing and tracking to strengthen systems that are in place for public health officials as these infections continue to become more common. "is is a kingdom of organisms that is going to be challenging to deal with," Dr. Chiller said. "It's here to stay." n

• Cover