NU 503 Assignment 1: Health Policy Brief Part I

NU 503 Assignment 1: Health Policy Brief Part I

Medication errors, considered as preventable events, cause over 7,000 deaths each year and cost close to $21 billion (Rodziewicz et al. 2021). Patient safety outcomes can only happen when providers and stakeholders remain accountable and share patient safety responsibilities. The rising costs of healthcare require stakeholders to develop policies, through legislations, to enhance safety outcomes for patients when they visit healthcare settings (AHRQ, 2021). The purpose of this policy brief is to describe the issue of patient safety outcomes and offer recommendations on how stakeholders can address the problem and enhance quality care delivery. The policy brief has sections to communicate the need for policy change to mitigate safety concerns that lead to adverse events and even fatalities in the health care system in the country.

Description of Issue/Problem: Patient Safety Outcomes

Patients expect to receive safe and quality care outcomes when they interact with the health care system and

NU 503 Assignment 1 Health Policy Brief Part I
NU 503 Assignment 1 Health Policy Brief Part I

providers. However, over 7,000 individuals lose their lives each year due to patient safety related events like medication errors and inability to access quality care interventions. Patient safety outcomes remain a national issue that require effective legislation to protect the lives of Americans accessing and interacting with the health care system.

NU 503 Assignment 1 Health Policy Brief Part I
NU 503 Assignment 1 Health Policy Brief Part I

Healthcare is a highly regulated industry in the country with numerous state and federal laws, rules, regulations and compliance measures governing the interaction among different stakeholders that include providers, payers, patients and regulatory agencies (Fiedler & Young, 2021). Most of these legislations focus on enhancing accessibility and quality care services. Patients cannot attain these aims when they fail to have safety outcomes in their interactions with providers and the system.

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Existing legislations like the Patient Safety and Quality Improvement Act of 2005 create voluntary reporting system to improve available data in assessing and resolving patient safety and quality care issues. The law provides federal privileges and confidentiality protection for patient safety information as a way of encouraging analysis of medical errors. However, despite the existence of this law and other system-wide and organizational-specific measures, patients’ safety incidents continue to occur (Rodziewicz et al., 2021). The implication is that providers fail to comply with existing laws and regulations placing the lives of millions of patients at increased risks of long-term disabilities and even death.

The World Health Organization (WHO) (2018) asserts that adverse events caused by unsafe care is one of the leading causes of death and disability in the world. The organization estimates that in high-income nations like the U.S., one in every ten patients is harmed while getting care from healthcare settings or providers. Accordingly, harm emanates from a host of adverse events, with over 50% of them being preventable. Rodziewicz et al. (2021) observe that medical errors are a critical public health problem and a leading cause of mortality in the country. The implication is that medical errors affect patient safety outcomes and thus the need for solutions and strategies that will allow providers and the system to offer quality care outcomes and adhere to existing legal frameworks.

In its policy brief, the American Academy of Nursing on Policy (2019) asserts that nurse working conditions exacerbate medical errors and lower patient safety outcomes. The policy position of the association is that healthcare organizations and regulatory entities must address factors that increase the risk for adverse events like nursing shortage. As nurses work shift and long hour (SWLWH), they become fatigued, sleep few hours and get poor health which affect overall patient and public safety (Caruso et al., 2019). As such, having patient safety outcomes require efforts from all stakeholders in the health care system as the problem arises from multiple factors affecting the entire health care system and infrastructure.

Potential Stakeholders

The need for patient safety outcomes attracts different stakeholders in the industry. These include federal and state governments in different areas like legislature and executive who are keen on enhancing quality care delivery and accessibility. The existing regulatory agencies at both state and federal levels have established policies and measures to safeguard patient safety that practitioners should follow and implement to mitigate the increased cost burden of adverse events that include fatalities. The second level of stakeholders are health care organizations and professional associations keen on attaining quality care and better patient outcomes. These include hospitals and their networks, professional associations like the American Nurses Association, health insurance providers and healthcare professionals like nurses and physicians. These stakeholders would also like to avoid potential litigations that may arise due to perceived negligence and establish robust quality care improvement systems for increased service delivery and bottom line.

The third stakeholders are patients, their families, communities and populations (Bell et al., 2018). These are users of healthcare services and also potential victims who suffer from lack of safety or poor safety outcomes. As end users of healthcare services, they should be involved in the policy for effective implementation of changes to enhance safety when interacting with the healthcare system and providers (AHRQ, 2021). These stakeholders all follow existing legal provisions and ensuring that there is effective implementation means that they should understand the magnitude of the issue and appreciate policy recommendations for long-term results.

Pending Legislation on Patient Safety Outcomes

Existing legislations like the Patient Safety and Quality Improvement Act of 2005, the Patient Protection and Affordable Care Act (PPACA) and Health Insurance Portability and Accountability Act of 1996 (HIPAA) among others provide certain provisions that protect patients’ safety. However, these legislations are not explicit on the specific actions that local, state, and federal authorities and players should take when providers violate the safety requirements leading to adverse events for patients. The Congressional Bill S.3380 – Patient Safety Improvement Act of 2020 sponsored by Senator Sheldon Whitehouse mandates The Health and Human Services Department to take certain actions concerning healthcare-related infections, antimicrobial stewardship and patient safety.

The bill provides that the department must offer incentives to state medical boards to offer education on patient safety issues like conditions for licensure (Congress.GOV, 2021). Under the bill, the Centers for Medicare and Medicaid Services (CMS) should have harmonized quality measure reporting protocols and requirement through collaboration with all stakeholders that include patient groups, insurers and health professional associations. Further, as a condition to participate in Medicare, the bill requires board members of hospitals to get training on appropriate patient safety topics to ensure that they understand the different facets of the issue. The bill implies that while existing requirements on patient safety are critical based on different standards by professional bodies and state and federal government, these regulations should be harmonized for effective coordination and implementation to improve adherence and reduce the occurrence of adverse events.

Plan for the Health Brief: Recommendations

Evidence from multiple sources show that patient safety outcomes are a concern for all stakeholders; right from regulatory bodies to patient groups and professional associations representing nurses and other health care practitioners (Rodziewicz et al., 2021). At the core of this brief are two objectives. The first objective is to communicate critical information on need for changes to existing laws as demonstrated by the Congressional bill on patient safety. This brief recommends the following actions. One that stakeholders support the current bill to harmonize all safety requirements under CMS as a condition to participate in both Medicare and Medicaid. Secondly, that stakeholders form an advocacy coalition to push for and lobby for the passage of the bill. Lastly, the objective recommends that stakeholders increase awareness of the importance of patient education on safety outcomes and use evidence to improve their understanding on the significance of their participation in policy changes.

The second objective of this policy brief plan is to ensure that organizations and providers create safety cultures through implementation of evidence-based practice interventions with the sole purpose of understanding the importance of patient safety outcomes. Moreover, the organizations should make certain that education of nurses and changes in work schedules to reduce the risk for increased adverse events form the foundation of this policy brief. Also, the provision of information and effective communication and dissemination of evidence on the benefits of patient safety outcomes are essential in addressing the current problem (ANA, n.d). Lastly, incentivizing State Boards of Nursing and Medical Boards will help them get enough resources to offer training and ensure that health care practitioners have the right training on patient safety for better outcomes.


The policy brief on patient safety outcomes shows the need for changes to the current legal frameworks at both state and federal levels. This brief is explicit that a coordinated collaboration will lead to creation of a harmonized framework under one entity like the CMS for effective implementation to avoid overlaps and duplication that may hinder adherence to these rules. The brief seeks to offer stakeholders information and strategies to ensure that entities and providers achieve patient safety outcomes.


Agency for Healthcare Research and Quality (AHRQ) (2021). Nursing and patient safety.

American Nurses Association (ANA) (n.d). Health policy.

Bell, S. K., Gerard, M., Fossa, A., Delbanco, T., Folcarelli, P. H., Sands, K. E., … & Walker, J.

(2017). A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships. BMJ quality & safety, 26(4), 312-322. doi: 10.1136/bmjqs-2016-006020.

Caruso, C. C., Baldwin, C. M., Berger, A., Chasens, E. R., Edmonson, J. C., Gobel, B. H., … &

Tucker, S. (2019). Policy brief: Nurse fatigue, sleep, and health, and ensuring patient and public safety. Nursing outlook, 67(5), 615-619.

Congress.GOV. (2021). S.3380 – Patient Safety Improvement Act of 2020.

Fiedler, M. & Young, C. L. (2021). Current debates in health care policy: A brief overview.

Lawton, R., O’Hara, J. K., Sheard, L., Armitage, G., Cocks, K., Buckley, H., … & Wright, J.

(2017). Can patient involvement improve patient safety? A cluster randomized control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. BMJ quality & safety, 26(8), 622-631. doi: 10.1136/bmjqs-2016-005570.

Rodziewicz, T. L., Houseman, B. & Hipskind, J. E. (2021). Medical Error Reduction and

            Prevention. StatPearls [Internet].

World Health Organization (WHO). Patient safety.