CAPSAC grew out of a statewide need to improve California’s patient safety culture.

In the fall of 2005, a group of California Healthcare Foundation (CHCF) Healthcare Leadership Fellowship graduates formed a task force to improve an aspect of how health care is delivered in California. They quickly determined that there were several patient safety issues that needed to be addressed.

The task force members discussed forming a statewide collaborative similar to the Massachusetts Coalition for the Prevention of Medical Errors. In 2007, they spoke with Paula Griswold, the executive director of the Massachusetts Coalition, as well as Jim Conway, a senior faculty member of the Institute of Healthcare Improvement. Griswold and Conway shared how the Massachusetts Coalition had developed and encouraged the task force members to network and create a similar statewide coalition in California.

Adding urgency to the task of forming a California patient safety coalition was a state bill (S.B. 1301) that, if passed, would have required mandatory reporting of medical errors. A forum to discuss the impact of the legislation and promote transparency around the reporting of medical errors was needed.

The task force members also recognized that efforts to improve patient safety in California were hampered because hospitals, medical groups, medical malpractice carriers, regulators and other key stakeholders faced artificial barriers that kept them from working together on the problem.

The Palo Alto Medical Foundation hosted the group’s first roundtable meeting in June of 2007. The attendees included the Deputy Director of the California Department of Public Health Center for Health Care Quality (CHCQ), as well as representatives from the following organizations:

  • California Hospital Association
  • California Medical Association
  • The Doctors Company
  • Kaiser Permanente
  • Sutter Health
  • Lumetra
  • Catholic Healthcare West
  • The Woodland Clinic

After a series of meetings, the group adopted a charter and a name: The California Patient Safety Action Coalition. This was the true birth of CAPSAC. Next, it applied for and received a grant from the Center for Health Care Professions to hold a convening meeting in July 2008.

A few months before the meeting, the newly formed CAPSAC strategically partnered with risk management consulting firm Outcome Engineering to assist in the spread of the concepts of a Fair and Just Culture – the approach to improving patient safety systems that CAPSAC advocates. Outcome Engineering works with states across the country on improving patient safety systems, and CAPSAC wanted to make sure its efforts were aligned with those of other states, including North Carolina, Minnesota, Pennsylvania, Florida and Arizona.


Today, CAPSAC has grown to include more than 60 healthcare organizations. It is run with donations of employee time and materials by member organizations, such as the Palo Alto Medical Foundation, as well as with funds remaining from the initial grant from the Center for Health Care Professions and new donations. The Center for Health Care Professions at UCSF administers the funding.

CAPSAC members met in July 2014 and confirmed that they would form a collaborative partnership with the University of Wisconsin, School of Industrial Engineering and its System Engineering Initiative for Patient Safety. In May of 2015, the members held a two-and-a-half-day course for health care professionals on Human Factors Engineering (HFE) in medicine and patient safety.