The U.S. Department of Health and Human Services, in conjunction with the Agency for Healthcare Research and Quality, released a report to Congress this month exploring effective strategies for reducing medical errors.  

The report, which was required by the Patient Safety and Quality Improvement Act of 2005 to be submitted to Congress no later than December 21, reviewed progress in the act's implementation so far and proposed future tactics for the healthcare industry.

"The landmark Patient Safety and Quality Improvement Act of 2005 created a unique and powerful framework that is supporting patient safety and quality improvement work across the United States," said researchers in the report. "That framework stands ready to support the collaborative national effort needed to make further progress in improving the safety and quality of healthcare," they added.  

WHY IT MATTERS  

The Patient Safety Act included several key provisions, including the creation and maintenance of a network of patient safety databases and the establishment of a process for entities to be listed as patient safety organizations.  

So far, said the report, the federal government has implemented several of those requirements, such as by developing a standardized form of data collection and launching the Network of Patient Safety Databases in 2019.  

"The NPSD currently includes more than 2 million records. Voluntary patient safety event reports, as currently operationalized, are unable to produce a representative sample of the underlying provider or patient populations," noted the authors.  

Looking ahead, the HHS and AHRQ outlined several strategies for reducing medical errors:  

• Using analytic approaches in patient safety research, measurement and practice improvement to monitor risk.
• Expanding the use of research methodologies that explore and capture the complexity of patient safety problems.
• Implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure.
• Encouraging the use of patient safety strategies as outlined in the National Action Plan by the National Steering Committee for Patient Safety.

They also encouraged the development of learning health systems, aimed at speeding the adoption of the most promising evidence to improve care.  

"Every day, clinical encounters generate data pertaining to healthcare procedures and patient outcomes," read the report. "When these data are systematically collected and analyzed, the results can point to risks and hazards in healthcare delivery and contribute to the evidence on safe practices.  

"In a learning health system, that evidence is aligned with safety culture and the mission of healthcare organizations to drive improvements in clinical practice," it continued.

The report notes that patient safety organizations can play an important role in supporting the evolution toward learning health systems.  

THE LARGER TREND  

Health IT experts have heralded the role learning health systems may play in progress for years, with the Institute of Medicine stressing their importance way back in 2012.

But a fully interoperable, AI-driven system is still in progress.

In May 2021, standards expert Dr. Blackford Middleton, stressed the importance of a learning health system for improving quality, lowering cost and improving patient and provider experiences. He noted that learning health systems have been key for the AHRQ evidence-based Care Transformation Support. 

"With a learning health system, we can capture a true picture of patient experience and progress toward shared goals, and improve our understanding of best practices and the public health at local, community and national levels," he said.

ON THE RECORD  

"Although the concept of a learning health system is relatively new, it may be an important driver to encourage use of effective patient safety strategies," read the HHS and AHRQ report.  

"The learning health systems perspective provides a blueprint for integrating data and evidence into clinical practice with the goal of achieving safer, higher quality care," it continued.

"It may also help to reinforce that safety is an attribute of the entire healthcare system and the first responsibility of every participant, rather than a discrete program or silo of activities."