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

Disclosures

Medscape General Medicine. 2000;2(3) 

In This Article

The NPSF Agenda for Research in Patient Safety

This document establishes the strategy and tactics for research and development on patient safety that will be pursued by the NPSF in its early years. We define patient safety as the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare. These events include "errors," "deviations," and "accidents." Safety emerges from the interaction of the components of the system; it does not reside in a person, device, or department. Improving safety depends on learning how safety emerges from the interactions of the components. Patient safety is a subset of healthcare quality.

There are 2 broad categories of patient safety issues in need of research: safety problems, which are superficial characteristics, and underlying mechanisms, which are more generic, deeply rooted characteristics of the healthcare system. Efforts to improve safety must attack both categories. Improvement requires understanding technical work, identifying organizational factors that influence the safe conduct of work, and identifying new vulnerabilities that are introduced when interventions are made.[10] Solutions should not be implemented without assessing how they will work in the real world. Also, safety research must examine how changes may alter error tolerance, how operators detect and recover from incipient failures, and how unintended side effects create new paths to failure.

Understanding the nature of technical work includes learning about the basis for expertise, success, and what factors challenge them. Learning about underlying systemic factors that influence performance means, for instance, learning about when incidents and accidents occur, anticipating new areas of concern as change occurs, finding deeper and more generic patterns in failures, and developing, prototyping, and evaluating new approaches to safety.

The interventions that may improve safety performance or ameliorate patient safety problems include: improving mechanisms of patient identification; computerized drug order entry systems; bar code scanning of blood products; language barriers and cultural differences that may lead to poor provider/patient communications; regulation of physician work hours; new systems of safety reporting; and use of new training modalities, eg, simulation.

Some examples of issues that are not priorities for patient safety are: problems that are not generally preventable, anticipated complications of medical treatment, known side effects of drugs or of procedural interventions, agendas that are much broader than safety; reducing malpractice claims or tort reform, nonserious injuries or quality of care alone, patient satisfaction, and reducing the cost of care.

We define the term "research" as encompassing development of techniques and interventions in addition to the acquisition of new knowledge. Research and development (R&D) is needed to: (1) reveal the existence of and/or determine the frequency and magnitude of the occurrence of safety problems; (2) assess the contribution of underlying human or system characteristics to safety problems; (3) assess the prevalence of underlying human or system characteristics in healthcare that are analogous to those known to be important arbiters of safety in other hazardous industries; (4) develop, pilot, and evaluate techniques or approaches to modify human or system characteristics (eg, safety reporting, education and training, modified procedures for drug order entry); and (5) develop, pilot, and evaluate techniques or approaches to maintain patient safety efforts as integral to the culture of healthcare delivery. We must also seek to promote the development of a cadre of experts and expertise in this area.

All forms of research must be considered, including those that are quantitative and qualitative. Innovation is especially important. New methods for understanding basic mechanisms, new measurements, and new ways to test interventions are needed. To do that, it is important to understand the "stories" that describe failures and to dig deeper into the issues that are essential to creating solutions.[10,11]

For now, we counsel against the NPSF itself being a research agency rather than an agency that supports others to do research. Conducting research would drain the limited administrative resources of the NPSF and requires competitively low overhead expenses that would be difficult to achieve. Furthermore, every decision to fund targeted research must recognize that NPSF overhead will be required to manage the project with the necessary oversight.

The following strategies are the basis for the agenda for NPSF-sponsored research: (1) foster and encourage investigator-initiated research; (2) target 1 or 2 special areas that are likely to achieve positive results in the time frame of a few years; and (3) leverage the resources of the NPSF by convincing other funding sources of the importance and scientific validity of patient safety research topics.

Priority should be given to projects that: (1) have high leverage, eg, large output for small input; (2) have a broad impact on the population; (3) improve understanding of what is generally referred to as preventable problems, especially those brought about by human error and system failures; (4) propose innovative and creative methods of study or solutions to problems; (5) involve interdisciplinary research teams; (6) do not have other sources of funding.

This strategy will be implemented by the following tactics: (1) supporting investigator-initiated research projects via the existing evaluation process; (2) if the NPSF Executive Committee identifies a topic of special importance, a subsolicitation can be devoted to that topic within the routine request for proposals. Proposals for that topic would be evaluated separately from the general investigator-initiated proposals. If funding permits, special RFPs can be generated for specific topics; (3) the Research Committee will develop and maintain a list of currently recognized problems for which the Committee and the Foundation's Executive Committee may decide to solicit targeted applications or for which opportunities to collaborate with other organizations may seem particularly advantageous; (4) the Foundation should be ready to respond to inquiries from other agencies about potential collaboration on projects that meet the joint goals of the agencies; an ad hoc committee should be appointed and convened by the Chair of the Research Program to assess such inquiries; (5) the NPSF should publicize the need for research on patient safety issues as an important part of a comprehensive strategy of research to improve the health of the nation's citizens; (6) investigator-initiated and targeted programs should seek a balance between research on underlying mechanisms and interventions addressed to currently identified problems.

Success of research is difficult to measure objectively. Indicators will include publications reporting the results of NPSF-funded research, the use and implementation of the research, and how the information from the NPSF grant-funded studies is used elsewhere. Expansion of priorities of federal agencies and private foundations to include patient safety efforts in their own agendas would be an important measure of success for the NPSF agenda. The NPSF should attempt to determine whether the efforts in its grant program and educational activities have an impact on front-line providers.

This document sets forth the strategy and tactics for research and development that will be pursued by the NPSF in its early years. Together, these constitute an "agenda" for research and development in patient safety. No formula exists that could be applied to setting this agenda. The problem of patient safety begins with the lack of a common definition, the disparate views of the topic, and the lack of a systematic process for collecting and analyzing scientific data from which to set an agenda objectively. Yet, to effect real change -- especially in the underlying culture of the system that delivers healthcare -- and to improve clinical outcomes, a strategy complete with tactics is needed. Absent scientific data, an informed intuitive process was used to establish the agenda, with success to be measured by the product judged as having face validity by the Board of Directors of the NPSF. The agenda will be modified over time to incorporate new understanding and concepts.

We begin by examining the definition of patient safety and set boundaries for the general areas that should have the attention of the NPSF. We then consider the kinds of information from which an agenda can be formed. We present the general nature of the safety issue. The agenda is then set in some broad and some specific terms.

The broad questions we address are:

  1. What is patient safety and what is patient safety research?

  2. What are the goals of research concerning patient safety?

  3. How much should the NPSF's research agenda be driven by a targeted agenda vs the independent ideas of investigators?

  4. How much should research focus on underlying mechanisms of unsafe systems vs the development and testing of remedies for specific safety problems?

  5. What are the forms of a strategy and an agenda to improve patient safety? By what processes should the research strategy and agenda of the NPSF be developed, maintained, and updated so that it is consistent with contemporaneous needs of the patient safety movement and the NPSF?

  6. By what measures will we know if our goals are being achieved?

What is Patient Safety?

Background
The term "patient safety" is becoming widely used. As does the term "safety" alone, it means different things to different people. Those who formed the NPSF had in mind some concept, individually and collectively, of what patient safety is. Yet, until now, no one has articulated what constitutes the spectrum of issues to which the NPSF should give its attention. Where does safety end and quality begin? Which problems are better addressed in a context of medical complications or public health? What should be the boundaries of patient safety in which the NPSF operates its research and other programs? Defining Characteristics of Patient Safety
Based on these materials, patient safety can be defined as incorporating the following points:
  1. Patient safety has to do primarily with the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare itself. It should address events that span the continuum from what may be called "errors" and "deviations" to "accidents." (See model in Figure 1 below.)

  2. Safety emerges from the interaction of the components of the system. It is more than the absence of adverse outcomes and it is more than avoidance of identifiable "preventable" errors or occurrences. Safety does not reside in a person, device, or department. Improving safety depends on learning how safety emerges from the interactions of the components.

  3. Patient safety is related to "quality of care," but the 2 concepts are not synonymous. Safety is an important subset of quality. To date, activities to manage quality, such as quality assurance, continuous quality improvement, total quality management, etc, have not focused sufficiently on patient safety issues.

Using several information-gathering processes conducted by the NPSF, coupled with historic materials about safety in other domains, the outlines of patient safety can be defined. These processes are:

  1. The request for letters of intent (LOIs) to apply for grant funding from the NPSF.

  2. The criteria resulting from the Research Committee's deliberations on which LOIs to invite to submit full proposals.

  3. The survey of Committee members regarding possible topics to be considered as relevant and important to patient safety.

  4. The topics addressed in abstracts submitted to the 1998 conference on patient safety.

  5. The presentations at the 1997 Workshop on Assembling the Scientific Basis for Progress on Patient Safety and position papers statements by experts participating in that conference.

Continuum of Patient Safety
Patient safety research efforts span a continuum from understanding the roots of system and individual failure, through developing interventions to mitigate those failures, to assessing the effect of implementation of error reduction processes.

Examples on the continuum are:

Epidemiology of Error Error Mechanisms Developing Interventions Implementation of Error Reduction Processes
Observational studies of error incidence Analysis of technical work Creation and trial of experimental reporting system Effectiveness testing of broad-scale reporting system
Descriptive studies of error typology Analysis of error processes Creation and trial of error reduction process Effectiveness testing of simulation for improving performance

Efforts to improve safety are needed at all points along this continuum. Furthermore, improvement requires an understanding of technical work, of organizational factors that influence the safe conduct of that work, and, especially, of new vulnerabilities that are introduced whenever an intervention is made. It is not sufficient to suggest implementing solutions to identified safety problems without assessing how they will work in the real world. Safety research must examine how changes may alter error tolerance, support detection and recovery from incipient failure, and recognize and address unintended side effects that create new paths to failure.

Patient safety research can be defined in terms of 2 broad categories of problems: safety problems and underlying mechanisms. Below is a definition of this rubric of patient safety and some examples of issues that are in need of attention.[12]

"Safety Problems": Failures in specific health areas. Some refer to these as "phenotypes," ie, the superficial characteristics of the system as opposed to underlying mechanisms:

  • Prevalence and cause of medication errors by healthcare personnel in all settings;

  • Surgery or procedure on wrong part of body;

  • Errors in performance of hazardous activities (surgery, anesthesia, radiation therapy, etc);

  • Misdiagnosis;

  • Selection of inappropriate treatment; and

  • Nosocomial infection

Underlying Mechanisms for Safety Problems: Often called "genotypes" because they are more generic, deeply rooted characteristics of healthcare systems:

  • Latent failure in organizational structure or processes;

  • Safety culture and the blame processes;

  • Safety reporting, eg, incident reporting and other mechanisms for learning about systemic vulnerabilities;

  • Organizational learning processes and barriers;

  • Production pressure;

  • Fundamental human limitations -- performance-shaping factors;

  • Fatigue and sleep deprivation;

  • Stress;

  • Human factors design in devices and systems;

  • Coordination and cooperation across people and boundaries (coordination infrastructure);

  • Education and training processes for safe procedures; and

  • Special problems of sectors that are severely resource-limited.

Elements of Research

  1. One of the most important approaches to patient safety research is to understand the nature of technical work, including:

    • The basis for expertise and success,

    • The factors that challenge expertise and success, and

    • Balancing a view of the practitioner's world with a view of the various aspects of human performance that play out in that setting.

  2. This work goes beyond the surface characteristics to discover underlying patterns of systemic factors that influence performance. Developing this understanding supports:

    • Learning about systemic vulnerabilities when incidents and accidents occur;

    • Anticipating new areas of concern as change occurs;

    • Finding deeper and more generic patterns in failures;

    • Developing, prototyping, and evaluating new approaches; and

    • Linking the patterns in these to specific healthcare contexts.

  3. Among the interventions that may improve safety performance or ameliorate patient safety problems are (some of which are related to issues above):

    • Improving mechanisms of patient identification;

    • Computerized drug order entry;

    • Bar code scanning of blood products;

    • Regulation of physician work hours;

    • Changes in healthcare culture;

    • Reorganization of healthcare;

    • Language barriers and cultural differences that may lead to poor provider/patient communications;

    • New systems of safety reporting; and

    • Use of new training modalities, eg, simulation

    For some of these, research is needed to prove efficacy; for others, research is needed to test implementation or effectiveness.

  4. The following are examples of issues that are not priorities for patient safety:

    • Problems that are not generally preventable;

    • Anticipated complications of medical treatment, known side effects of drugs or of procedural interventions;

    • An agenda that is much broader than safety;

    • Reducing malpractice claims or tort reform*;

    • Involving nonserious injuries or quality of care alone;

    • Patient satisfaction*; and

    • Reducing the cost of care*

* These items could have a priority when they have a direct connection to patient safety as we have defined it.

The patient safety movement and the NPSF have many goals in addressing the issues of patient safety. Research is an important component of a broader strategy to improve safety. The term "research" encompasses "development" of techniques and interventions in addition to the acquisition of new knowledge. In particular, research is needed to:

  1. Reveal the existence of and/or determine the frequency and magnitude of the occurrence of known or new safety problems (broadly interpreted this could be considered as questions of epidemiology);

  2. Assess the contribution of underlying human or system characteristics to safety problems;

  3. Assess the prevalence of underlying human or system characteristics in healthcare that are analogous to those known to be important arbiters of safety in other hazardous industries;

  4. Develop, pilot test, and evaluate techniques or approaches to modify human or system characteristics, including such items as safety reporting, education and training, modified procedures for drug order entry, etc; and

  5. Develop, pilot test, and evaluate techniques or approaches to maintain patient safety efforts as an integral part of the culture of healthcare delivery, similar to what exists in the aviation and nuclear power industries.

Beyond adding to the actual knowledge and techniques generated by patient safety research support, we must seek to encourage and support research in patient safety to promote the development of a cadre of experts and expertise in this area.

There are several ways to address the support of research. The 2 main strategies include:

  1. Rely on proposals initiated by investigators, and

  2. Target support to topics deemed important in the research agenda.

These strategies are not mutually exclusive. There are advantages and disadvantages to each. In addition, the decision about which strategies to pursue, and to what degree, will be dependent on the financial resources of the Foundation at a given time. Currently, the funds available to support research are modest, and the field of research in patient safety is in its infancy. Thus, the Foundation's most important role is as a catalyst, providing seed money for innovative work at the "pilot" stage, rather than definitive funding for projects likely to achieve definitive, dramatic results. Success is likely to come from some surprising directions rather than "obvious" solutions.

  1. Investigator-initiated Research Support

    Relying on investigator-initiated proposals has many advantages. Investigator-initiated research is the central core of most biomedical research. Programs that allow for individual investigators to define the scope of their projects solicit ideas from the broadest source possible. This minimizes the risk of missing important and novel ideas due to preexisting prejudices within the NPSF. It invites participation at the earliest stages from those in the best position to carry out the work. It is the most powerful way to develop a cadre of investigators active in this arena, since it is likely that even investigators who are unsuccessful in receiving funding from this source will seek funding elsewhere. It lends itself to the solicitation of innovation and pilot work that, by necessity, appears to be the NPSF's most likely current focus.

    The main disadvantage of relying on investigator initiation is that investigators may not have the same view of the importance of topics as does the NPSF itself through its officers and Research Committee. To the extent that NPSF-perceived critical topics are not addressed by investigators' proposals, research on these topics will be missed.

  2. Targeted Support

    Targeted support has advantages. To the extent that particular topics or issues can be agreed upon as critical, targeted support can guarantee solicitation of proposals to address them. Further, targeted support may be more likely to bring forward the full spectrum of investigators and organizations able to address a particular area. A specific target also may lead to higher public visibility and be the nucleus for raising funds, possibly allowing more funds to be addressed to the targeted area than to the diversity of ideas generated by individual investigators.

    The disadvantages of targeted support are: (1) that it presumes that the critical topics or approaches can be articulated; (2) that it may tend to promote a parochial view of the broad issues of patient safety; and (3) that its very advantages in visibility and fundraising may tend to squeeze out investigator-initiated support that may have a benefit in the long run. Indeed, in a field as young as patient safety, targeting research may artificially narrow the innovative and creative processes necessary to develop a sustainable patient safety effort.

    Among the topics and areas that should be considered for targeted support when resources are available include:

    • incident reporting systems

    • medication error

    • safety culture

    • patient handoffs and discontinuities in care

    • missed diagnosis

    • misdiagnosis

    • medical device design

    • coordination of medical work

    • understanding of the nature of expertise

    • analyses of technical work

  3. Other Avenues of Research and Development

    Independent of these 2 strategies, there are other avenues by which the NPSF may pursue R&D related to patient safety.

    One is to collaborate with other agencies in supporting projects that appear likely to serve the research and development goals of the NPSF (regardless of where those projects are initiated). This approach has the advantage of leveraging NPSF support via collaboration. Conversely, it runs the risk of funding projects that will already be funded while leaving unfunded novel ideas that, largely for bureaucratic reasons, have not obtained funding by another source.

    Another useful strategy is to foster within other agencies the desire to provide research support themselves for projects that would otherwise be within the purview of the NPSF.

  4. Research conducted directly by or under the administration of the NPSF

    Opportunities will arise for research to be conducted directly by or managed by the staff or others directly affiliated with NPSF. That is, the NPSF could be considered a research agency rather than merely an agency that supports research. We counsel against that at the current time, since it would drain the very limited administrative resources of the NPSF and would require unachievable overhead to be a competitive research organization.

Being a characteristic of systems, patient safety is a complex phenomenon. The healthcare systems in place today have the characteristics they do because of a complicated interaction of organizational, economic, legal, social, and technical factors. These systems evolved into their current state and no portion of them can be altered easily even if data were available to show unequivocally the need for change.

As is the case with disease research, an agenda for patient safety research and development must achieve a balance between research and development that addresses specific avenues to attack currently identified problems vs research on the fundamental underlying mechanisms that lead to the suboptimal safety. Ultimately, the research on underlying mechanisms can be more powerful since it can, in theory, show what characteristics of the system must be changed to achieve fundamental alterations in the processes of care. However, such research is difficult, will take a long time to achieve any measurable results, will by its nature travel down some blind alleys, and is likely to involve some contentious political issues.

Research along these lines would focus on such things as organizational structure and process in healthcare, especially in comparison to principles of high reliability organizations.[4,13,14] These lines of inquiry would try to delineate exactly what characteristics of the healthcare system(s) promote errors or adverse outcomes and which of these characteristics are amenable to modification, and would outline the potential side effects of any modifications. It is likely that this kind of research will involve comparisons of healthcare to other high-hazard activities in society, and it will be important to determine the ways in which healthcare differs intrinsically and irrevocably from other industries.

However, just as medical science does not give up on finding new treatments for cancer as it attempts to understand the basic processes of the disease, it is prudent to investigate the surface level of identified problems and to study reasonable approaches already available to deal with them. Examples of these abound, but medication errors and procedures on the wrong body part are examples that readily come to mind. Although a full understanding of how such events occur (and continue to occur despite the industry's awareness of the problems) will require a more complete understanding of underlying mechanisms, reasonable approaches exist that may be expected to ameliorate these problems, if admittedly not to completely eradicate them.

In assessing the proper balance of these activities for the NPSF, we should be cognizant that existing agencies are more likely to fund research on currently identified problems, whereas there are few funding agencies to deal with the longer-term research on underlying mechanisms. For example, research on medication errors may well be funded by organizations involved in the manufacture, distribution, and regulation of pharmaceuticals. These same organizations are less likely to fund "basic" research on the mechanisms of error and error propagation in complex organizations. Therefore, the Foundation should be careful not to lean too heavily in the direction of research on currently available avenues to attack currently identified problems, especially if in doing so it would reduce its ability to fund research on fundamental mechanisms with a longer time horizon, but with more profound potential implications.

Because catastrophic outcomes are rare and measures of preventable outcomes are difficult to establish, research in patient safety does not easily fit into conventional quantitative models. Thus, all forms of research must be considered, including those that are quantitative and qualitative. Innovation is especially important. Research and development are needed in all areas, including the development of new methods for understanding basic mechanisms, new measurements, and ways to test interventions. Understanding the "stories" that describe failures and digging into the deeper issues that are essential to creating solutions are important.

The agenda must be based on a set of research strategies. The agenda itself is a set of tactics to achieve the strategy. The problems encompassed in patient safety are so large and diffuse as to resist formation of a hard agenda, ie, a set of projects that will meet some goal of reducing patient injuries from presumably preventable events. Implementation of tactics will be molded both by the resources available in any year, as well as by opportunities that present themselves.

The following strategies are the criteria for the agenda for NPSF-sponsored research.

  1. Foster and encourage investigator-initiated research. This will secure the broadest base of research ideas with a constant (yearly) update of the most novel and important techniques and concerns while fostering the development of a research cadre. Funded ideas will yield results. Many unfunded ideas will acquire funding from other sources. In the first years, NPSF should give priority to proposals that have a more direct path to implementation in patient care, but also support research on more underlying mechanisms where the other funding criteria are strongly met.

  2. Target 1 or 2 special areas that are likely to achieve positive results in the time frame of a few years. The topics may arise from unsolicited proposals to the NPSF or from ideas brought forward by members of the NPSF Board of Directors, programs, or committees.

  3. Leverage the resources of the NPSF by convincing other funding sources of the importance and scientific validity of patient safety research topics.

The general basis on which to judge support of projects from any source should be to give priority to those that:

  • have high leverage, eg, large output for small input;

  • have a broad impact on the population;

  • improve understanding of what is generally referred to as preventable problems, especially those brought about by human error and system failures;

  • propose innovative and creative methods of study or solutions to problems;

  • involve interdisciplinary research teams; and

  • Understand or solve problems for which there are no other sources of funding.

The following tactics will implement this strategy:

  1. Support investigator-initiated research projects meeting the general criteria for research and development funding. At current levels of funding for the research program, no fewer than 2 grant awards should be made to purely investigator-initiated projects. This investigator-initiated research would go through the standard grant cycle review.

  2. If the Executive Committee of the Foundation believes that a particular topic in any year is of sufficient importance to warrant a special call for proposals within the current grants program, a subsolicitation within the overall request for proposals (RFP) can be devoted to that topic. Proposals for that topic would be evaluated separately from the general investigator-initiated proposals. The research evaluation of proposals submitted under the subsolicitation should be conducted under the auspices of the Research Program, with special guidance for priorities given by the Executive Committee, if necessary.

  3. If funding permits, special RFPs can be generated for specific topics. This will be especially advantageous in situations where the nature of the topic can allow sufficient funds to be raised to support more complex studies and interventions.

  4. The Research Committee will develop and maintain a list of currently recognized problems for which the Committee and the Foundation's Executive Committee may decide to solicit targeted applications, or for which opportunities to collaborate with other organizations may seem particularly advantageous. This list should not be seen as an exhaustive definition of critical issues in patient safety.

  5. The Foundation should be ready to respond to inquiries from other agencies about potential collaboration on projects that meet the joint goals of the agencies. It would be advisable to maintain contingency funding available for these "targets of opportunity." When such inquiries are received by the NPSF, an ad hoc committee drawn from the members of the Research Committee should be appointed and convened by the Chair of the Research Program to assess whether (1) the inquiry is within this document's framework with regard to patient safety; and (2) whether the substantive proposal is technically feasible. If the Research Program Chair determines that expertise from the Research Program cannot adequately assess the proposal, eg, the proposal requires assessment by experts in and/or familiar with other industries, then the Chair will obtain the relevant expertise by accessing the NPSF National Health Care Safety Council. The ad hoc committee will then provide substantive comments on the proposal with a recommendation as to whether the Board of Directors and Executive Committee should proceed based on the proposal's fit with the themes in this document and the project's technical rigor.

  6. The NPSF should initiate meetings with other biomedical and social research funding agencies, both private and governmental, to publicize the need for research on patient safety issues as an important part of a comprehensive strategy of research to improve the health of the nation's citizens.

  7. Both investigator-initiated and targeted programs should seek a balance between research on underlying mechanisms and interventions addressed to currently identified problems. On a continuing basis, the Research Committee shall assess the projects supported to date in terms of this balance for guidance for its own deliberations and those of the Executive Committee.

Success is relative. On one level, success should be measured by the information generated by the grant program. Substantive information gained from projects funded by NPSF will be an important measure as to the direct effects of the grant program. Thus, publications reporting the results of NPSF-funded research will be an important method of measuring the success of the research agenda.

The use and implementation of such work also are important considerations in measuring success. Has the information from the NPSF grant-funded studies been put to use elsewhere? Have others obtained similar results in their systems? Have others used the study information in expanded and extended work? These assessments can be accomplished through a determination of citations of studies using NPSF funds.

A broader goal of the NPSF is education of the public regarding patient safety. Is the NPSF successful in providing such education? News clips, media coverage, survey data, and public recognition of such activities are measures of the NPSF's success in delivering its message. To enhance its probability of success, NPSF must work with other organizations to educate the public regarding patient safety. Mere recognition of NPSF does not constitute success.

Another related goal is the ability for NPSF to increase the visibility of patient safety among other organizations. Thus, for example, expansion of priorities of federal agencies and private foundations to include patient safety efforts in their own agendas would be an important measure of success of the NPSF agenda.

Finally, and most difficult, the NPSF should attempt to determine whether the efforts in its grant program and educational activities has an impact on front-line providers. The best systems and reporting mechanisms in the world are ineffective if providers do not recognize them as important, if they are not accessible to providers, and if they are not used by providers. Survey data that accesses hospital, managed care organization, and private practice administrator and provider (including resident physician) knowledge and implementation of patient safety work is essential in assessing success. This subject may be a relevant topic for NPSF grant funding.

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