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PTAC experts urge better measurement, tech and outpatient focus to reduce preventable harm
Summary
PTAC members and experts emphasized gaps in safety measurement, the scale of outpatient and omission errors, and both the promise and risks of AI and EHR tools in detecting and preventing harm.
Dr. Chinny Pulluru, PTAC co-chair and chief medical officer at Agilon Health Care, led a detailed presentation framing patient safety as a systems problem and calling for improved measurement, surveillance of near misses, and payment designs that incentivize reliability.
The presentation summarized prevalence and economic estimates cited in the meeting: an international OECD estimate of more than $600 billion annually in preventable harm and a large study estimating about 795,000 Americans per year suffer permanent disability or death due to diagnostic errors. Pulluru noted that many safety events are not captured in existing reporting systems, and that outpatient care and errors of omission are increasingly prominent as care shifts out of hospitals.
Panelists listed federal and accrediting actors that contribute to the safety ecosystem, including the Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), The Joint Commission, NCQA, Leapfrog and IHI, and summarized CMS-linked payment programs tied to safety (Hospital-Acquired Condition program, Hospital Readmissions Reduction Program, Merit-based Incentive Payment System (MIPS), and the TEAM model).
Dr. Lee Mills and other PTAC members underscored the importance of patient-reported data and routine surveys to surface near misses; Mills described a practice that reviewed survey comments weekly and used them to identify systemic near misses. Larry Kosinski and others pressed for clinical decision support tools and better EHR integration to reduce omission errors.
Speakers cautioned that technology is not a panacea: AI and automated surveillance can scale detection but also create new failure modes if deployed without human-centered design and rigorous evaluation. The committee framed its next steps around identifying actionable safety metrics, exploring how technology can be scaled responsibly, and designing payment mechanisms that reward prevention and improvement.
The meeting recessed for a break and will reconvene with expert panels and a public comment period the next morning.
