The President’s Council of Advisors on Science and Technology (PCAST) has released its recommendations to dramatically improve patient safety in the United States in a report to President Joe Biden. Patient safety is an urgent national public health issue. The report says that approximately one in four Medicare patients experience adverse events during their hospitalizations, with many resulting in catastrophic outcomes. More than 40 percent of these events are determined to be due to preventable errors. Efforts to address this urgent problem are underway across federal agencies, but more must be done. This report seeks to empower existing and new efforts that will transform patient safety by outlining recommendations in four main areas.

Here is a summary of the four recommendations:

Recommendation 1: Establish and Maintain Federal Leadership for the Improvement of Patient Safety as a National Priority

It is recommended that The President should establish a White House-led Transformational Effort on Patient Safety, that commits to more comprehensively engage all relevant government agencies to help solve the critical challenges in both the public and private sectors.

Recommendation 1.A: Appoint a Patient Safety Coordinator, reporting to the President, on efforts to transform patient safety among all relevant government agencies.

Recommendation 1.B: Establish a multidisciplinary National Patient Safety Team and ensure inclusion of persons from populations most affected.


Recommendation 2: Ensure That Patients Receive Evidence-Based Practices for Preventing Harm and Addressing Risks.

The President should direct the HHS Secretary, in collaboration with the Department of Defense (DoD), and Department of Veterans Affairs (VA), to require the appropriate federal agencies to develop a list of high-priority harms, evidence-based practices, and system-level mitigation strategies. This will eliminate preventable harms, including “never events” that should never occur in healthcare. Far too many patients do not benefit from these evidence-based practices. It is time to create and act on a guarantee: that every American will experience care that corresponds to the leading safety practices.

Recommendation 2.A: Identify and address high-priority harms and promote patient safety though incentivizing the adoption of evidence-based solutions and requiring annual public reporting immediately with an aspiration of more frequent reporting in the future.

Recommendation 2.B: Create a learning ecosystem and shared accountability system to ensure that evidence-based practices are implemented and goals for reduced harms and risks of harm for every American are realized.

Recommendation 2.C: Advance interoperability of healthcare data and assure free access to the tracking of harms and use of evidence-based solutions.

Recommendation 2.D: Improve safety for every healthcare worker through supporting a just culture of patient safety and clinician safety in healthcare systems.


Recommendation 3: Partner with Patients and Reduce Disparities in Medical Errors and Adverse Outcomes.

It is crucial to engage relevant stakeholders in the nation’s effort to reduce harm from unsafe care. This should include partnering and collaborating with the patients, families, and communities most impacted by unsafe care. Implementing evidence-based solutions in healthcare settings should include patient-centred approaches and give special attention to collaborating with those communities that have experienced long-standing disparities.

Recommendation 3.A: Implement a “whole of society approach” in the transformational effort on patient safety.

Recommendation 3.B: Improve data and transparency to reduce disparities.


Recommendation 4: Accelerate Research and Deployment of Practices, Technologies, and Exemplar Systems of Safe Care.

It is critically important to accelerate the development and deployment of new technologies and evidentiary foundations for safe healthcare, so that errors, injuries and healthcare disparities are minimized.

Recommendation 4.A: Develop a National Patient Safety research agenda.

Recommendation 4.B: Harness revolutionary advances in information technologies.

Recommendation 4.C: Develop federal healthcare delivery systems’ capacities and showcase results as exemplars for safer healthcare.

Access the full report here: