Agenda for Research and Development in Patient Safety

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NPSF Research Agenda3. Other Avenues of Research and DevelopmentIndependent of these two strategies, there are other avenues by whichthe NPSF may pursue R&D related to patient safety.One is to collaborate with other agencies in supporting projects that appearlikely to serve the research and development goals of the NPSF (regardlessof where those projects are initiated). This approach has the advantage ofleveraging NPSF support via collaboration. Conversely, it runs the risk offunding projects that will already be funded while leaving unfunded novelideas that, largely for bureaucratic reasons, have not attained funding byanother source.Another useful strategy is to foster within other agencies the desire toprovide research support themselves for projects that would otherwisebe within the purview of the NPSF.4. Research conducted directly by or under the administration of the NPSFOpportunities will arise for research to be conducted directly by or managedby the staff or others directly affiliated with NPSF. That is, the NPSF couldbe considered a research agency rather than merely an agency that supportsresearch. We counsel against that at the current time since it would drainthe very limited administrative resources of the NPSF and would requireunachievable overhead to be a competitive research organization.D. Research on BasicMechanisms vs. IdentifiedSafety ProblemsBeing a characteristic of systems, patient safety is a complex phenomenon.The health care systems in place today have the characteristics they dobecause of a complicated interaction of organizational, economic, legal,social, and technical factors. These systems evolved into their current stateand no portion of them can be altered easily even if data were available toshow unequivocally the need for change.Just as in research on diseases, an agenda for patient safety research anddevelopment must achieve a balance between research and developmentthat addresses specific avenues to attack currently identified problemsversus research on the fundamental underlying mechanisms that lead to thesub-optimal safety. Ultimately the research on underlying mechanisms canbe more powerful since it can, in theory, show what characteristics of thesystem must be changed to achieve fundamental alterations in the processesof care. However, such research is difficult, will take a long time to achieveany 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 organizationalstructure and process in health care, especially in comparison to principlesof high reliability organizations. These lines of inquiry would try to delineate8
NPSF Research Agendaexactly what characteristics of the health care system(s) promote errorsor adverse outcomes, which of these characteristics are amenable tomodification, and 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 todetermine in what ways health care is different intrinsically and irrevocablyfrom other industries.However, just as medical science does not give up finding new treatmentsfor cancer as it attempts to understand the basic processes of the disease,it is prudent to investigate the surface level of identified problems and tostudy reasonable approaches already available to deal with them. Examplesof these abound, but medication errors and procedures on the wrongbody part are two examples that readily come to mind. While a fullunderstanding of how such events occur (and continue to occur despitethe industry’s awareness of the problems) will require a more completeunderstanding of underlying mechanisms, reasonable approaches existthat may be expected to ameliorate these problems, if admittedly not tocompletely eradicate them.In assessing the proper balance of these activities for the NPSF, we shouldbe cognizant that existing agencies are more likely to fund researchconcerning currently identified problems, whereas there are few fundingagencies to deal with the longer term research on underlying mechanisms.For example, research on medication errors may well be funded byorganizations involved in the manufacture, distribution, and regulation ofpharmaceuticals. These same organizations are less likely to fund “basic”research on the mechanisms of error and error propagation in complexorganizations. Therefore, the Foundation should be careful not to lean tooheavily in the direction of research on currently available avenues to attackcurrently identified problems, especially if in doing so it would reduce itsability to fund research on fundamental mechanisms with a longer timehorizon, but with more profound potential implications.E. Methodologies forPatient Safety ResearchBecause catastrophic outcomes are rare and measures of preventableoutcomes are difficult to establish, research in patient safety does not easilyfit into conventional quantitative models. Thus, all forms of research mustbe considered, including those that are quantitative and qualitative.Innovation is especially important. Research and development are neededin all areas, including the development of new methods for understandingof basic mechanisms, new measurements and ways to test interventions.Understanding the “stories” that describe failures and digging intothe deeper issues that are essential to creating solutions are important.9
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