Researchers Studying Patient Safety

A serious discussion took place on December 2, 2014 at the “Zero Harm: Charting a New Course for Patient Safety in our Commonwealth” event held in Boston presented by the Betsy Lehman Center for Patient Safety and Medical Error Reduction.

Betsy Lehman was a prominent Boston Globe health reporter who died in 1994 from a tragic and   preventable medical error where she received an overdose of a chemotherapy drug. In the years since her death, improved patient safety measures have been implemented but preventable medical errors remains a critical issue in Massachusetts.

In 2014, the Betsy Lehman Center commissioned three major pieces of research aimed at understanding the current patient safety landscape in Massachusetts. Ben Blendon Professor of Health Policy and Political Analysis at the Harvard School of Public Health (HSPH) explained how HSPH interviewed more than 1,200 Massachusetts adults to find out how they viewed medical errors in Massachusetts.

The research resulted in an independent report “The Public’s Views on Medical Error in Massachusetts commissioned by the Betsy Lehman Center in collaboration with the Health Policy Commission.

Research shows that nearly one quarter of the residents in Massachusetts report that they or a person close to them experienced a medical error in the past five years while 59 percent said that the error resulted in serious health consequences. The most common type of medical error was misdiagnosis, which was reported by 51 percent of the affected respondents.

Eric C. Schneider, MD Principal Researcher at RAND Corporation, interviewed more than 40 Massachusetts expert observers of patient safety efforts including healthcare industry representatives, clinicians, policy makers, and consumers for the report “Patient Safety in the Commonwealth of Massachusetts”.

The researchers found that awareness of patient safety within the medical community has increased over the past 20 years, but the goal of achieving safer care for everyone has been elusive. Various approaches used to reduce the risk of harm to patients in hospitals has not been widely adapted and has not been pursued equally in doctors’ offices, community health centers, long-term care facilities, ambulatory surgical centers, and other settings like home care.

According to Schneider, “The value of transparency and public reporting of medical errors and their negative effects on patients remains controversial in the Commonwealth. Healthcare facilities report types of serious problems like medication errors, infections, and falls but views are mixed about the usefulness of the data for making care safer.”

The National Academy for State Health Policies (NASHP) Senior Program Director Jill Rosenthal surveyed state officials in all 50 states and the District of Columbia to find out how adverse medical events are reported in those states.

The researchers compiled the report, “Adverse Event Reporting in Massachusetts and Other States: Status and Trends in 2014”, noting that 26 states and the District of Columbia have reporting systems monitoring occurrence of some categories of adverse medical events.

Also, Massachusetts is the only state with two distinct adverse event reporting systems that requires reporting from some of the same facilities. Perhaps streamlining, coordinating, or potentially consolidating reporting processes across the two systems could help address provider concerns dealing with the reporting burden.

The report also found that despite complementary goals, adverse event reporting systems in Massachusetts and elsewhere seem to stand alone from states’ broad quality improvement, cost containment, and other delivery system reforms.

The report points out that reporting system officials in the Commonwealth could partner with other entities in the states to produce patient safety events, initiatives, or learning collaborations that would leverage reporting system data to address specific areas of need.

To view the three research reports, go to

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