Nearly 30 years after Betsy Lehman died from an accidental overdose of chemotherapy drugs, Massachusetts facilities are still grappling with the issue of medical errors.
On Wednesday, the center formed in her name, in collaboration with a consortium of health care experts and industry groups, launched a new road map to educate and hold accountable all those involved in the state’s health care system. The recommendations include the establishment of a statewide program of health care safety education and training for all staff and administrators, including front-line workers; boosting patient and family engagement in safety improvements; and streamlining and coordinating the various state systems that track safety data to reduce duplication and information gaps.
“There is low awareness, low expectations, and everyone gets away with it because there isn’t accountability,” said Barbara Fain, executive director of the Betsy Lehman Center for Patient Safety. “That’s what the road map is designed to change.”
The 1994 death of the 39-year-old Boston Globe health care reporter and mother of two at Dana-Farber Cancer Institutesent shock waves through the health care system, and the Betsy Lehman Center for Patient Safety was formed in response, committed to reducing medical errors in Massachusetts health care facilities.
Despite some strides, progress has been slow. In 2019, one in five Massachusetts residents experienced a medical error in their own care or in the care of a household or close family member.
A 2019 report by the Lehman center found that in a typical year, there were 62,000 cases of preventable harm to Massachusetts patients, resulting in $617 million in excess health insurance claims. Additionally, a study published in 2023 in the New England Journal of Medicine looking at 2018 data from 11 Massachusetts hospitals found that 7 percent of all patient admissions involved a preventable adverse event related to medication, surgery, or health care associated infections.
The pandemic has worsened many metrics of patient safety, with higher rates of health care associated infections, falls, and pressure ulcers.
The data, however, only reflect incidents in places that are tracked. There are a number of settings — such as physicians’ offices — that do not collect safety data and have very few requirements to report safety events.
“As more care moves to ambulatory settings, even into people’s homes, there are all kinds of safety risks. They are different than the risks you have in a hospital or nursing home setting,” Fain said. “So what are we doing to address those risks at this point?”
The center brought together dozens of government, provider, and health care groups in the Massachusetts Healthcare Safety and Quality Consortium to understand the hurdles to progress and develop a plan to overcome them.
The center is seeking funding through the fiscal 2024 state budget process for a number of initiatives, including a pilot to implement safety monitoring regimes known as “continuous improvement systems” in places like small primary care offices, with the hope to scale the systems if proven effective. The organization also hopes to fund a curriculum around safety that is tailored to all the different roles in a provider’s organization, from leadership down to the receptionist.
The largest portion of the funding would create a pilot program in six to eight hospitals to leverage an IT system to run in the background of institutions’ electronic medical records to identify events as they occur and help prevent future ones.
Currently, providers must manually report safety issues into dozens of different systems, depending on the nature of the event. However, even within those systems, institutions have varying degrees of compliance with reporting.
Groups recognize that the work is difficult and comes at a time of increasing burnout and frustration for front-line health care providers.
Dr. Doug Salvador, chief quality officer at Baystate Health, who participated in the consortium, said strategies that improve safety can ultimately lead to efficiencies that decrease the burdens on the front-line workforce. Additionally, as evidenced by the number of groups that helped develop the road map, the weight of the work will be borne by everyone in health care, not just front-line workers.
“I don’t think it’s just the health system and the delivery side’s responsibility to solve the problem,” Salvador said. “That’s one of the things I’m optimistic about. It will take all of us to improve safety for patients in this country and in the state. … Part of the discussions in creating this road map forced all of us together to ask the difficult questions about why more progress hasn’t been made, what are the real reasons for that, and what will really work? I don’t see this as an impossible task, I see this as a long term task.”