• Provide funding to support the National Agenda for Action for Patients and Families, including development of a Patient and Family Resource Center
• Support a central role for the Agency for Healthcare Research and Quality (AHRQ) in coordinating a multifaceted, multi-industry national patient safety initiative, which includes sufficient funding to carry out research and development activities to support and advance public and private patient safety initiatives across the nation
• Create financial incentives for hospitals to support the business case for patient safety
• Support patient safety legislation aimed at protecting confidentiality and promoting disclosure, such as HR 663, which passed the House by a nearly unanimous vote in March, or S 720, which currently awaits Senate action

Krawisz asked the lawmakers not to look to more regulation and more mandates, but to move toward a culture of constructive action and evidence-based planning that is designed to solve system-wide problems. He told the Subcommittee to consider the effectiveness of existing programs, such as those used by the Aviation Safety Reporting System. “Programs, such as these, search for workable and sound policies and procedures that promote the collection of valid and reliable data. Ultimately, the result is improved patient safety,” he said. “Our common goal must be to detect errors and system barriers and to make corrections before a patient is harmed.”

Effective patient safety measures must include all elements of the healthcare system and not focus only on individual components. “The key,” Krawisz said, “is to move away from a culture of shame and blame and move toward a culture of partnership and collaboration between healthcare providers and consumers.” Krawisz noted that organizations like NPSF, an independent, nonprofit organization focused on research and education, are making inroads in generating awareness, providing education, and convening patient safety stakeholders to create objective action plans for patient safety initiatives. He told the Subcommittee that NPSF is committed to making patient safety a national priority. “Health professionals and organizations in the public and private sector should be encouraged to report and evaluate health system errors, and to share their experiences with others in order to prevent similar occurrences.”

Krawisz concluded his testimony by highlighting 10 best practices for effective patient safety programs. NPSF urges hospitals and health systems to implement these practices, which include the following:

• Secure management commitment
• Create organizational patient safety goals and objectives
• Develop an effective information system
• Develop an emergency response program
• Improve processes
• Provide education and training
• Utilize networking opportunities
• Create and reinforce awareness
• Use reward and recognition programs to change behavior
• Enforce compliance

In addition to Krawisz, other individuals testifying at today’s hearing include: James Bagian, Director, National Center for Patient Safety, Veterans Affairs Department, and Member of the NPSF Board of Directors; Carolyn Clancy, Director, Agency for Healthcare Research and Quality; Dennis O’Leary, President, Joint Commission on Accreditation of Healthcare Organizations; David Page, President/CEO, Fairview Health Services, and Member of the NPSF Board of Directors; and Suzanne Delbanco, Executive Director, The Leapfrog Group.

About the National Patient Safety Foundation
The National Patient Safety Foundation was founded in 1996 by the American Medical Association, CNA HealthPro, 3M and contributions from the Schering-Plough Corporation. The NPSF is an independent, nonprofit research and education organization. It is an unprecedented partnership of healthcare practitioners, institutional providers, health product providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators and policy makers committed to making health care safer for patients. Through leadership, research support, and education, the NPSF is committed to making patient safety a national priority. For more information, about the NPSF, visit www.npsf.org.
On the Net: Congress site: http://www.npsf.org/congress/