Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

The Veterans Affairs (VA) health system is responsible for both systemic achievements and challenges. This hearing examined a series of problems occurring in the VA system including unexplained deaths of patients. Strategies presented during testimony to remedy these situations include improving employee background checks, credentialing gaps and response to reported clinician performance concerns.

Enabling patients to access their medical records has been found to enhance patient–clinician communication and uncover errors. This hearing explored the importance of providing patient access to personal health information to improve care. Testimonies discussed the need to have one integrated patient record and to design patient portals around human factors approaches to augment usability.

In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.

A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.

This testimony details the US Food and Drug Administration (FDA) response to drug shortage trends and advocates for the agency to have more leverage with manufacturers to address burgeoning shortages.

This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.

This testimony highlights insights from a policy leader, chief medical officer, and hospital leader on US government efforts to improve health care quality and safety.

This Congressional testimony summarizes a 2008 investigation and responds to its findings. It suggests that prioritization of effort, data consistency, and data compatibility are needed to improve health care–associated infection reduction efforts.

This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.

This hearing focused on quality and safety of treatment for patients with end stage renal disease in the Medicare population, as well as recent research on Medicare payment and costs for patients with this condition.

This congressional committee hearing explored possible changes to the U.S. medical liability system to more effectively help patients, families, and physicians who have been affected by failures in medical care.

These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.

This hearing provides testimony from the Agency for Healthcare Research and Quality, the Joint Commission on Accreditation of Healthcare Organizations, the American College of Surgeons, the Medical Association of Georgia, and the National Partnership for Women & Families on the current state of patient safety and quality as well as suggested areas for improvement.

In this statement, AHRQ Director Carolyn Clancy reviews the work of the Agency for Healthcare Research and Quality and other health care entities to build support for research and improvements in patient safety.

This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide reporting initiative.