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

The National Patient Safety Foundation

Founded in 1997, the National Patient Safety Foundation (NPSF) is an independent, nonprofit research and education organization dedicated to making patient safety a national priority and promoting a culture of safety.[7] It is housed at the American Medical Association and led by a Board of Directors that includes healthcare clinicians, institutional providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators, and policy makers dedicated to making healthcare safer for patients. The formation of the NPSF is one indicator recognizing the patient safety problem and the will of responsible organizations to work toward solutions. The NPSF's mission is to "improve measurably patient safety in the delivery of healthcare by its efforts to identify and create a core body of knowledge; identify pathways to apply the knowledge; develop and enhance the culture of receptivity to patient safety; raise public awareness and foster communication about patient safety; and improve the status of the Foundation and its ability to meet its goals." Among its activities in pursuit of this mission, the NPSF launched a research grant program in 1998. The objective of this program is to promote studies leading to prevention of human errors, system failures, and any forms of preventable injuries in healthcare and the resulting adverse consequences to patients. NPSF took as its model the program established by the Anesthesia Patient Safety Foundation (APSF) in 1985. With few resources, APSF has for 13 years funded 3-4 grants annually.[8,9] Its current funding level is a maximum of $65,000 per award (overhead costs are not funded). The NPSF program in its first year funded 4 awards for a total of $350,000. A second round of awards totaling $359,000 was announced in October 1999 for grants to begin on January 1, 2000. The maximum award is $100,000 (including allowance for maximum 15% overhead costs). While this is but a fraction of the funding of programs that attack most healthcare issues, it is a start toward creating incentives for researchers and to stimulate other foundations and government agencies to direct some of their resources at this topic.

The NPSF Agenda for Research in Patient Safety is reprinted below in its entirety. It includes background on the patient safety issue, a working definition of patient safety, strategy and tactics for research, examples of patient safety research topics, goals of safety research, considerations for targeted vs. investigator-initiated research, methodologies, and measures of success. The agenda was developed by the NPSF Research Program, whose members deliberated for 10 months to arrive at this consensus document. (The committee members involved in that process are listed at the end of this article). Embedded in the agenda are comments that reflect the rationale that was used and especially the acknowledgment that this was, by necessity, a process guided more by intuition than by scientific data. Indeed, the lack of data is the driving force behind creation of the agenda.

An agenda for patient safety research is a starting point for this discussion. Other efforts are needed to hone the agenda and make it more applicable to a national research effort, one that is supported by other organizations as well as by NPSF. To this end, the NPSF, via a contract from the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) has embarked on a project to catalogue patient safety research projects at selected federal agencies and foundations. The objective is to identify the extent of patient safety research and mechanisms through which it is funded. The cataloguing will result in a list of patient safety research projects that key government agencies and selected healthcare-related foundations now support. Also, perceptions of patient safety research and expectations for future studies will be ascertained via in-person interviews with agency leaders and program managers.

Substantive information gained from the cataloguing process will identify unmet needs for data and information in patient safety research. The NPSF also plans to co-host a meeting to identify and focus on areas where research is needed, ascertain sources and mechanisms for funding that research, and encourage collaborative activities among interested parties. The objective of this meeting will be to articulate what is known and to identify additional research opportunities for the future. Representatives of funding agencies will be invited to identify patient safety research topics and how they correlate with the mission of each organization.

These activities will be a large step toward working collaboratively to create a national research agenda to define areas where the impact can be maximized and made most visible through joint action. It is imperative that the healthcare community take full advantage of the momentum to work synergistically to escalate patient safety activities.