,i  #aag? ,,congress  #b;d ,session  ,h4
 ,r4 #icgg  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,decemb] #a1 #bjbb,ms4
 ,b>ragn introduc$ ! foll[+ bill2 :i* 0 
ref]r$ to ! ,committee on ,en]gy &      
,comm]ce1 & 9 addition to ! ,committees 
on ,vet]ans' ,affairs1 & ,education &   
,labor1 = a p]iod to be subsequ5tly     
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to e/abli% ! ,national ,pati5t
 ,safety ,bo>d4  #a4 ,%ort title ,?is   
,act may be cit$ z ! ,national ,pati5t  
,safety ,bo>d ,act ( #bjbb4  #b4        
,national ,pati5t ,safety ,bo>d  7a7    
,e/abli%m5t ,!re is h]eby e/abli%$ an   
indep5d5t ag5cy to be kn[n at !         
,national ,pati5t ,safety ,bo>d 79 ?is  
section ref]r$ to z ! ,bo>d7 = ! purpose
 ( prev5t+ & r$uc+ pati5t safety ev5ts4 
7b7 ,duties  7#a7 ,9 g5]al ,= ! purpose 
/at$ 9 subsection 7a71 ! ,bo>d %all--   
7,a7 support ,f$]al dep>tm5ts & ag5cies 
9 monitor+ & anticipat+ pati5t safety   

ev5ts ) pati5t safety data surveillance 
te*nologies2  7,b7 provide exp]tise to  
/udy ! context & causes ( pati5t safety 
ev5ts & solutions2 &  7,c7 =mulate      
recomm5dations & solutions to prev5t    
pati5t safety ev5ts f occurr+4  7#b7    
,annual audit ,! ,bo>d %all und]go an   
annual audit4  7#c7 ,annual reports to  
,congress  7,a7 ,submission ,! ,*air ( !
 ,bo>d %all submit annual reports to !  
,congress on ! progress ( ! ,bo>d 9     
a*iev+ ! purpose /at$ 9 subsection 7a74 
7,b7 ,cont5ts ,ea* annual report "u     
subp>agraph 7,a7 %all include-- 7i7     
input f ! director ( ea* division ( !   
,bo>d2  7ii7 detail$ solutions2  7iii7  
unaddress$ ne$s2 &  7iv7 any o!r        
in=mation det]m9$ by ! ,*air ( ! ,bo>d  
to be relevant to a*iev+ ! purpose /at$ 
9 subsection 7a74  7c7 ,he>+s2 reports  
7#a7 ,9 g5]al ,! ,bo>d may1 = ! purpose 
( c>ry+ out ?is ,act1 hold he>+s1 sit & 
act at times & places1 take te/imony1   
receive evid5ce1 & issue su* reports z !
 ,bo>d consid]s appropriate4  7#b7 ,no  

individually id5tifiable in=mation 9    
publications ,! ,bo>d 7includ+ any      
division1 subdivision1 or o!r compon5t  
!re(7 %all n include 9 any report or o!r
 publication in=mation t c be us$ to    
id5tify any pati5t1 heal? c>e provid]1  
or heal? c>e sett+4  7d7 ,memb]%ip  7#a7
 ,9 g5]al ,! ,bo>d %all be compos$ ( #e 
memb]s1 ea* nom9at$-- 7,a7 by !         
,presid5t1 by & ) ! advice & cons5t to !
 ,s5ate2 &  7,b7 = a t]m ( #f ye>s4     
7#b7 ,*air2 ,vice ,*air ,! ,bo>d %all h 
a ,*air & ,vice ,*air :o %all ea*-- 7,a7
 be designat$ by ! ,presid5t f among !  
memb]s ( ! ,bo>d appo9t$ "u p>agraph    
7#a72 &  7,b7 s]ve = a #c-ye> t]m4  7e7 
,/aff+ ,! ,*air ( ! ,bo>d may appo9t su*
 p]sonnel z ! ,*air consid]s appropriate
 to c>ry out ?is section4  7f7          
,organization ,! ,bo>d %all h-- 7#a7 an 
,(fice ( ! ,*air ( ! ,bo>d2  7#b7 a     
,pati5t ,safety ,ev5t ,monitor+         
,division1 to be head$ by a director    
appo9t$ by ! ,bo>d2  7#c7 a ,/udy       
,division1 to be head$ by a director    

appo9t$ by ! ,bo>d2  7#d7 a ,pati5t     
,safety ,solutions ,division1 to be     
head$ by a director appo9t$ by ! ,bo>d2 
7#e7 an ,adm9i/rative ,division1 to be  
head$ by a director appo9t$ by ! ,bo>d2 
&  7#f7 regional (fices4  7g7 ,pati5t   
,safety ,ev5t ,monitor+ ,division  7#a7 
,heal? ,c>e ,safety ,team  7,a7 ,9 g5]al
 ,= ! purpose /at$ 9 subsection 7a71 !  
,director ( ! ,pati5t ,safety ,ev5t     
,monitor+ ,division %all e/abli% &      
ma9ta9 a public-private team1 to be kn[n
 z a ,heal? ,c>e ,safety ,team1 to      
review1 update1 & prioritize pati5t     
safety ev5t measures & data s\rces      
relat$ to pati5t & provid] safety 9     
heal? c>e sett+s1 includ+ survey data1  
electronic heal? records data1 claims   
data1 heal? in=mation ex*ange data1 &   
reports ( pati5t safety ev5ts4  7,b7    
,recomm5dations ,! ,heal? ,c>e ,safety  
,team %all recomm5d to public & private 
entities pati5t safety data surveillance
 te*nologies & specifications ) !       
ability to id5tify & anticipate ! pati5t

 safety measures4  7,c7 ,memb]%ip ,!    
memb]%ip ( ! ,heal? ,c>e ,safety ,team  
"u subp>agraph 7,a7 %all include-- 7i7  
repres5tatives ) pati5t safety exp]tise 
f ! foll[+ ,f$]al ag5cies3 ! ,ag5cy =   
,heal?c>e ,rese>* & ,quality1 ! ,c5t]s =
 ,disease ,control & ,prev5tion1 !      
,c5t]s = ,m$ic>e  ,m$icaid1 ! ,dep>tm5t 
( ,vet]ans ,affairs1 ! ,(fice ( !       
,national ,coord9ator = ,heal?          
,in=mation ,te*nology1 ! ,indian ,heal? 
,s]vice1 ! ,(fice ( ,m9ority ,heal? ( ! 
,dep>tm5t ( ,heal? & ,human ,s]vices1 ! 
,heal? ,res\rces & ,s]vices             
,adm9i/ration1 ! ,sub/ance ,abuse &     
,m5tal ,heal? ,s]vices ,adm9i/ration1 ! 
,food & ,drug ,adm9i/ration1 ! ,national
 ,in/itutes ( ,heal?1 & ! ,unit$ ,/ates 
,prev5tive ,s]vices ,task ,=ce2 &  7ii7 
repres5tatives ( ! private sector )     
pati5t safety exp]tise1 repres5t+       
provid]s1 organiz$ labor1 heal? c>e     
organizations1 pati5ts1 payors1         
suppli]s1 v5dors1 manufactur]s1         
measurem5t develop]s1 & data te*nology  

exp]ts4  7#b7 ,obta9+ (ficial data ,to  
c>ry out ?is subsection1 ! ,director ( !
 ,pati5t ,safety ,ev5t ,monitor+        
,division may secure directly f any     
(fice or ag5cy ( ! ,dep>tm5t ( ,heal? & 
,human ,s]vices or ! ,dep>tm5t (        
,vet]ans ,affairs longitud9al1 real-"t1 
de-id5tifi$ pati5t data1 disaggregat$ by
 race1 e?nicity1 g5d]1 facility1 &      
location1 relat+ to pati5t safety ev5t  
measures4 ,^u reque/ ( ! ,director ( !  
,pati5t ,safety ,ev5t ,monitor+         
,division1 ! head ( ! respective (fice  
or ag5cy %all furni% t data to !        
,director4 ,! ,director %all ma9ta9 &   
use su* data consi/5t ) applicable      
privacy & confid5tiality law4  7#c7     
,website or sy/em ,! ,director ( !      
,pati5t ,safety ,ev5t ,monitor+         
,division %all create & ma9ta9 a website
 or sy/em1 to be kn[n z ! ,pati5t       
,safety ,report+ ,sy/em1 t c be us$ by  
pati5ts1 heal? c>e provid]s1 non-cl9ical
 /aff1 or any o!r p]son to report pati5t
 safety ev5ts to ! ,division4  7#d7     

,data access portal ,! ,director ( !    
,pati5t ,safety ,ev5t ,monitor+         
,division %all-- 7,a7 ent] into         
agreem5ts ) public & private entities1  
includ+ at ! ,/ate & local levels1 to   
opt into all[+ ! ,division to access !  
entity's longitud9al1 real-"t1          
de-id5tifi$ pati5t data1 disaggregat$ by
 race1 e?nicity1 g5d]1 facility1 &      
location1 relat+ to pati5t safety ev5t  
measures2  7,b7 ma9ta9 a data access    
portal to enable su* entities to submit 
su* data to ! ,division2 &  7,c7 ma9ta9 
& use su* data consi/5t ) applicable    
privacy & confid5tiality law4  7#e7     
,report+ ,! ,director ( ! ,pati5t       
,safety ,ev5t ,monitor+ ,division %all--
 7,a7 submit to ! ,heal? ,c>e ,safety   
,team ma9ta9$ "u p>agraph 7#a7 regul>   
reports on pati5t safety ev5t           
surveillance2 &  7,b7 prompt ! ,/udy    
,division :5 any ( ! foll[+ types (     
f9d+s are id5tifi$ 9 a geographic area  
or heal? c>e organization3 7i7 ,! mo/   
frequ5tly occurr+ major s\rces ( pati5t 

safety ev5ts4  7ii7 ,abnormal patt]ns ( 
pati5t safety ev5ts4  7iii7 ,unexpect$ly
 l[ numb]s ( pati5t safety ev5ts4  7iv7 
,racial1 e?nic1 social1 g5d]1 or        
geographic disp>ities4  7v7 ,unaddress$ 
reoccurr+ pati5t safety ev5ts4  7h7     
,/udy ,division  7#a7 ,9 g5]al ,!       
,director ( ! ,/udy ,division may       
conduct or support /udies ) respect to  
pati5t safety ev5ts1 includ+ to und]/&  
!-- 7,a7 circum/ances1 context1 &       
conditions t enable pati5t safety ev5ts2
 &  7,b7 causes or probable causes ( !  
high or l[ numb] ( pati5t safety ev5ts4 
7#b7 ,data %>+  7,a7 ,reque/ ,9 conduct+
 or support+ a /udy "u p>agraph 7#a71 ! 
,director ( ! ,/udy ,division may reque/
 f ! ,director ( ! ,pati5t ,safety ,ev5t
 ,monitor+ ,division su* in=mation z may
 be collect$ by ! ,pati5t ,safety ,ev5t 
,monitor+ ,division & relevant to !     
/udy4  7,b7 ,%>+ ,^u receipt ( su* a    
reque/1 ! ,director ( ! ,pati5t ,safety 
,ev5t ,monitor+ ,division %all %>e su*  
in=mation ) ! ,director ( ! ,/udy       

,division4  7#c7 ,/udy requirem5ts ,9   
conduct+ or support+ a /udy "u p>agraph 
7#a73 7,a7 ,/udy lead ,! ,director ( !  
,/udy ,division %all-- 7i7 appo9t an    
individual to s]ve z ! p]son 9 *>ge ( ! 
/udy 79 ?is p>agraph ref]r$ to z ! ,/udy
 ,lead72 &  7ii7 ve/ su* p]son )        
au?ority to det]m9e ! appropriate type (
 /udy1 assemble a /udy team ( exp]ts1   
id5tify ! /udy site or sites1 & ask any 
heal? c>e organization t exp]i5c$ !     
unexpect$ly high or l[ numb]s ( pati5t  
safety ev5ts = p]mission to conduct !   
/udy bas$ on prompts f ! ,pati5t ,safety
 ,ev5t ,monitor+ ,division4  7,b7 ,/udy 
team ,! ,/udy ,lead %all-- 7i7 assemble 
a team ( multidiscipl9>y exp]ts to      
improve ! und]/&+ ( high or l[ numb]s ( 
pati5t safety ev5ts 9 ! context ( !     
/udy1 includ+ by ga!r+ qualitative &    
quantitative in=mation to und]/&-- 7,i7 
! circum/ances1 context1 & conditions t 
enable ! pati5t safety ev5ts2 &  7,,ii7 
! causes or probable causes ( ! high or 
l[ numb] pati5t safety ev5ts2  7ii7     

include 9 su* team individuals ) !      
ability to /udy & und]/& ! int]action ( 
human abilities1 expectations1 &        
limitations ) "w environm5ts1           
te*nologies1 & sy/em design & o!r       
appropriate exp]ts f ! public & private 
sectors2  7iii7 prohibit su* team f     
releas+ in=mation obta9$ dur+ ! /udy    
prior to ! public release ( su*         
in=mation by ! ,national ,pati5t ,safety
 ,bo>d2 &  7iv7 ensure t su* team       
receives p]mission f ea* heal? c>e      
organization involv$ to-- 7,i7 ent]     
heal? c>e facilities p>ticipat+ 9 !     
/udy2 &  7,,ii7 communicate ) /aff1     
heal? c>e provid]s1 pati5ts1 v5dors1    
suppli]s1 contractors1 equipm5t         
manufactur]s1 & memb]s ( ! ,bo>d4  7,c7 
,appropriate type ( /udy ,! ,director ( 
! ,/udy ,division %all-- 7i7 create     
guidel9es & crit]ia to det]m9e !        
appropriate type ( /udy to be conduct$  
or support$1 includ+ :e!r ! /udy %\ld be
 virtual1 9-p]son1 or a special bo>d (  
inquiry2 &  7ii7 9 creat+ su* guidel9es 

& crit]ia1 take into acc\nt ! impact ( !
 pati5t safety ev5ts to be /udi$1 :e!r  
su* pati5t safety ev5ts may indicate a  
sy/emic risk1 & :at may pot5tially be   
le>n$ f ! /udy4  7,d7 ,novel infection &
 em]g5cy p&emic ,9 ! case ( a novel     
infection & em]g+ p&emic1 ! ,director ( 
! ,/udy ,division may e/abli% a special 
bo>d ( inquiry-- 7i7 to provide         
indep5d5t recomm5dations on a coord9at$ 
national prep>$ness & response plan2    
7ii7 to indep5d5tly monitor !           
implem5tation ( ! prep>$ness & response 
plan2 &  7iii7 to recomm5d te*nologies  
to support logi/ics & autonom\s real-"t 
rese>* to in=m evid5ce-bas$ treatm5t    
options & decisions4  7#d7 ,report+ ,!  
,director ( ! ,/udy ,division %all--    
7,a7 provide = ! submission to ! ,bo>d &
 ! ,pati5t ,safety ,solutions ,division 
(-- 7i7 at lea/ "o progress report on   
ea* /udy "u ?is subsection ov] ! c\rse (
 ! /udy2 &  7ii7 a f9al report ^u !     
conclusion ( ! /udy2  7,b7 include 9 a  
f9al report "u subp>agraph 7,a77ii7     

factual in=mation & analysis reg>d+ !   
probable causes ( ! high or l[ numb]s ( 
pati5t safety ev5ts be+ /udi$ & !       
recomm5dations ( ! ,pati5t ,safety      
,solutions ,division2 &  7,c7 make su*  
f9al report publicly available4  7#e7   
,response by ,bo>d ,^u receipt ( a f9al 
report "u p>agraph 7#d77;,a77ii71 !     
,bo>d may elect to-- 7,a7 adopt !       
report2  7,b7 "w ) ! ,/udy ,division to 
make *anges to ! report prior to        
adoption2 or  7,c7 require ! ,/udy      
,division to conduct or support fur!r   
/udies or revisions4  7#f7 ,tim+ ,!     
,director ( ! ,/udy ,division %all      
ensure t1 n lat] ?an #a ye> aft] !      
comm5cem5t ( a /udy "u ?is section--    
7,a7 ! /udy is complet$2 &  7,b7 ! f9al 
report is made publicly available       
pursuant to p>agraph 7#d77;,c74  7#g7   
,limitation on au?ority ,! ,/udy        
,division & any /udy team e/abli%$ "u   
?is subsection %all n h au?ority to     
det]m9e ! rights or liabilities ( any   
p]son ) respect to adv]se pati5t safety 

ev5ts4  7i7 ,pati5t ,safety ,solutions  
,division  7#a7 ,analysis ,:5ev] !      
,director ( ! ,/udy ,division provides a
 f9al report on a /udy pursuant to      
subsection 7h77#d71 ! ,director ( !     
,pati5t ,safety ,solutions ,division    
%all-- 7,a7 analyze su* report2 &  7,b7 
=mulate recomm5dations 7includ+         
solutions7 to prev5t ! pati5t safety    
ev5ts t 7 /udi$ f occurr+4  7#b7 ,work+ 
) ,heal? ,c>e ,safety ,team ,9 =mulat+  
recomm5dations 7includ+ solutions7 "u   
p>agraph 7#a71 ! ,director ( ! ,pati5t  
,safety ,ev5t ,monitor+ ,division %all--
 7,a7 9 consultation ) ! ,heal? ,c>e    
,safety ,team "u subsection 7g77#a71    
id5tify or develop solutions bas$ on !  
causes ( ! pati5t safety ev5ts t 7      
/udi$2 &  7,b7 include su* solutions 9 !
 recomm5dations4  7#c7 ,response by     
,secret>y ,n lat] ?an #ij days aft] !   
submission ( ! f9al report "u subsection
 7h77#d77;,a77ii71 ! ,secret>y ( ,heal? 
& ,human ,s]vices & ! ,secret>y (       
,vet]ans ,affairs %all publi% a response

 to ! recomm5dations4  7j7 ,adm9i/rative
 ,division  7#a7 ,9 g5]al ,! ,director (
 ! ,adm9i/rative ,division %all support 
! day-to-day activities ( ! ,bo>d1      
includ+ ) respect to communications1    
facility coord9ation1 %ipp+ & receiv+1  
supply inv5tory1 labor relations1 &     
human res\rce managem5t4  7#b7          
,subdivision ,! ,adm9i/rative ,division 
%all h a ,safety & ,equity ,subdivision 
:i* %all-- 7,a7 advise on1 analyze1 &   
publi% prop] safety guidel9es to ensure 
safe work+ conditions at ! ,f$]al1      
,/ate1 & local levels2  7,b7 create an  
equity plan to ensure t ! ,bo>d's       
programs & op]ations take into          
consid]ation ! implications (1 & rem$ies
 to address1 discrim9ation & disp>ities2
 &  7,c7 provide tra9+ to enhance       
employee safety compet5ce4  7k7         
,prohibition aga9/ admissibility z      
evid5ce ,any report or o!r publication (
 ! ,bo>d 7includ+ any division1         
subdivision1 or o!r compon5t !re(7 %all 
n be admissible z evid5ce1 or us$ = any 

purpose1 9 any ,f$]al or ,/ate action1  
suit1 or o!r judicial1 legislative1 or  
adm9i/rative proce$+4  7l7 ,protections 
= employees  7#a7 ,prohibition ,no      
employ] %all dis*>ge or 9 any mann]     
discrim9ate aga9/ any employee ) respect
 to comp5sation1 t]ms1 conditions1 or   
o!r privileges ( employm5t because !    
employee 7or an individual act+ at !    
reque/ ( ! employee7-- 7,a7 has         
coop]at$1 or is p]ceiv$ z be+ ab\t to   
coop]ate1 ) a /udy ( ! ,bo>d2 or  7,b7  
has submitt$ a report to ! ,pati5t      
,safety ,report+ ,sy/em ( ! ,pati5t     
,safety ,ev5t ,monitor+ ,division4  7#b7
 ,compla9t proc$ure  7,a7 ,9 g5]al ,an  
employee :o believes t he or %e has be5 
dis*>g$ or o!rwise discrim9at$ aga9/ by 
any employ] 9 violation ( ?is subsection
 may seek relief 9 accordance ) !       
proc$ures1 notifications1 burd5s ( pro(1
 rem$ies1 & /atutes ( limitation set =? 
9 section #bjhg7;b7 ( title #ae1 ,unit$ 
,/ates ,code4  7,b7 ,no limitation on   
rights ,no?+ 9 ?is subsection %all be   

deem$ to dim9i% ! rights1 privileges1 or
 rem$ies ( any employee "u any ,f$]al or
 ,/ate law or "u any collective b>ga9+  
agreem5t4 ,! rights & rem$ies 9 ?is     
subsection may n be waiv$ by any        
agreem5t1 policy1 =m1 or condition (    
employm5t4  7#c7 ,def9ition ,9 ?is      
subsection1 ! t]m employ] has ! mean+   
giv5 to su* t]m 9 section #c ( ! ,fair  
,labor ,/&>ds ,act ( #aich 7#bi         
,u4,s4,c4 #bjc74  7m7 ,def9itions ,9 ?is
 section3 7#a7 ,! t]m heal? c>e sett+   
means a hospital1 nurs+ facility1       
compreh5sive outpati5t rehabilitation   
facility1 home heal? ag5cy1 hospice     
program1 r5al dialysis facility1        
ambulatory surgical c5t]1 ph>macy1      
physician or o!r heal? c>e practition]'s
 (fice1 long-t]m c>e facility1 m5tal    
heal? treatm5t facility1 sub/ance use   
disord] treatm5t facility1 cl9ical      
laboratory1 or heal? c5t]4  7#b7 ,! t]m 
pati5t safety ev5t means an action or   
inaction t-- 7,a7 l$ to pati5t injury or
 h>m 9 a heal? c>e sett+2  7,b7 c\ld    

lead to pati5t injury or h>m z a        
precursor to injury or h>m 9 a heal? c>e
 sett+2 or  7,c7 c\ld h caus$ injury or 
h>m to ! pati5t b did n cause injury or 
h>m 9 a heal? c>e sett+ z a result (    
*ance1 prev5tion1 or mitigation4  7n7   
,au?orization ( appropriations ,to c>ry 
out ?is section1 !re is au?oriz$ to be  
appropriat$ #aaj1jjj1jjj = ea* ( fiscal 
ye>s #bjbc & #bjbd4