The National Patient Safety Foundation Agenda for Research and Development in Patient Safety

Jeffrey B. Cooper, PhD, David M. Gaba, MD, Bryan Liang, MD, PhD, JD, David Woods, PhD and Laura N. Blum, MA

In This Article


Despite remarkable advances in healthcare technology and delivery, a small but significant percentage of patients are harmed unintentionally each year.[1,2] In an increasingly complex healthcare system, underlying causes and risks are often hard to trace. Simple failures of a healthcare professional are rarely the cause of patient injury. More often, patient injuries are the result of flaws in the complex interactions among several individuals, the technologies they use, and the organizations in which they work. Overcoming these flaws and problems requires recognition that every activity in a healthcare setting has weaknesses that can compromise patient safety. Often these weaknesses are hidden until a unique combination of circumstances results in a near-miss or an actual injury.[3,4,5]

Efforts to improve the safety of healthcare are hampered by the absence of research. There are few research studies and data. There is no agency with patient safety as its primary mission. There is no coordinated, well-funded national research effort directed at the safety of patient care, few agencies that fund research directed at patient safety, no journal that regularly publishes reports about patient safety, and few textbooks that address the subject. These conditions are disincentives for investigators to enter the field. All of this points to the need for a coordinated program in research in this important area. This issue was highlighted in the recent, widely publicized report by the Institute of Medicine, "To Err is Human: Building a Safer Health System."[6] The first element of its recommended 4-part approach to build a safer healthcare system is "establishing a national focus to create leadership, research , tools and protocols to enhance the knowledge base about safety." (emphasis added)