NCHR’s Comments on AHRQ’s Draft Report on Improving Patient Safety

February 16, 2021

National Center for Health Research’s Public Comments on the Agency for Healthcare Research and Quality’s Draft Report to Congress Regarding Strategies to Improve Patient Safety

[Document Number 2020-27589]  

We are writing to express our views on the draft report to Congress regarding Strategies to Improve Patient Safety. The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research, policies, and programs on a range of issues related to health and safety. We do not accept funding from companies that make products that are the subject of our work.

Identifying and implementing strategies to improve patient safety and reducing medical errors is of utmost importance, and we strongly support this draft report. However, we have concerns over the limited scope of the report, and the title should be revised to better reflect that scope. 

The report highlights the importance and success of the 2005 Patient Safety Act and the important work patient safety organizations and providers have accomplished.  We commend that the draft report not only discusses effective strategies, but that it includes discussion about appropriate implementation of these strategies. For example, we agree with the report’s acknowledgement that context matters, and that strategies are not one-size-fits-all. What is most effective in one environment may not necessarily be in another. The draft report provides examples of successful implementation, which can be used to inform other organizations.

However, as we noted above, we are disappointed that the report has a limited scope. Despite the title, the report intentionally excludes many patient safety issues, such as ensuring that patients are fully warned about potential complications of a treatment, including off label indications that are not FDA approved, or treatments that do not meet the standards advised by medical experts. For this reason, the name of the report should reflect that it is not addressing patient safety as a whole, but rather is focused specifically on reducing medical error. We strongly recommend a revised title such as “Strategies to Improve Patient Safety by Reducing Medical Errors” for this report.