Six-month-old Jackson Kekula was brought to Boston Children’s Hospital for what should have been a routine procedure. He died after a series of medical errors. The Globe reported last month that the hospital paid $15 million to his family to settle a lawsuit while agreeing to corrective actions.
Jackson’s case was tragic and egregious, but medical errors at hospitals are unfortunately and inexcusably common.
Researchers published a study in January in the New England Journal of Medicine that found nearly 7 percent of a random sample of patients admitted to 11 Massachusetts hospitals in 2018 experienced a preventable, harmful event during their stay, and 1 percent — 29 patients — experienced serious preventable harm, including one death. Harmful events include things like drug side effects, surgical complications, falls, and infections.
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The Betsy Lehman Center for Patient Safety analyzed 2017 Massachusetts insurance claims data and found almost 62,000 medical errors had caused over $617 million in excess health insurance claims. In the center’s survey of almost 5,000 Massachusetts households, nearly 1,000 people reported experiencing a medical error in their or a family member’s care within the previous five years.
“These kinds of events happen routinely,” said Barbara Fain, executive director of the Betsy Lehman Center, which is a state government agency named after a Globe reporter who died after being given too high a dose of a chemotherapy drug. In addition to causing physical harm, Fain said medical errors cause people to lose trust in the health care system and avoid seeking care.
The good news is there is now a road map to improve safety in health care. In April, the Betsy Lehman Center released a report, based on work involving 35 public and private agencies and more than 115 individuals, that outlines steps for creating a safety culture in health care. It is imperative that the center and providers work together to translate the report’s broad goals into specific actions.
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One concrete recommendation is the creation of a pilot program where hospitals install software that can survey electronic health records and flag potential errors. Already, many hospitals use software that notifies providers when a patient is prescribed too high a dose of medication. Technology developed the last few years can also identify trends. For example, software can determine if a large number of patients developed pressure sores while waiting in the emergency department or if patients on a particular unit tend to get more catheter-related infections. Departments could then develop systemic policies to address those problems.
“We have a saying around quality, which is if you can’t measure it, you can’t manage it,” said David Bates, chief of general internal medicine at Brigham and Women’s Hospital and lead author of the January report, who also worked on the Betsy Lehman Center report. “If you just don’t know how many of a problem you’re having, it makes it much easier to not invest resources in that particular area.” Bates said relying on staff to report adverse events results in hospitals routinely underestimating problems.
While some hospitals nationwide have implemented this kind of software, none in Massachusetts have. Using the software raises questions that need to be worked out, like what liability hospitals are exposed to and what happens to the data. But humans make mistakes. Having a machine able to detect some of these mistakes could be life-changing.
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Many of the report’s recommendations are broad and will require more detailed planning to implement. These include proposals like creating a safety curriculum for health care providers and administrators; creating internal systems to identify and address safety issues; being more transparent with patients about errors; reducing workplace stress for providers; and combining state data on health care safety in a way that can be analyzed and publicly reported.
Fain said the goal is creating a culture of safety where institutions are taught how to prevent errors, then held accountable for their results.
There are examples of what this looks like. Kim Hollon, who retired as CEO of Signature Healthcare last year and was the Massachusetts Health and Hospital Association’s representative on the road map task force, hired consultants with experience in the airline and nuclear power industries to improve hospital safety.
Hollon said he implemented “employee-led process improvements,” requiring staff to discuss errors and suggest ways to improve. Each unit had a board where staff posted ideas for process improvements and their colleagues reviewed them. The system implemented over 8,000 suggestions annually, from establishing checklists to changing equipment. Hospital officials measured performance. For example, once it was discovered that staff on a unit were only scanning medication bar codes 70 percent of the time, staff identified problems, like machines breaking during the night, and worked to increase that number. Consultants recommended changes like using words — alpha for the letter A, for instance — when dictating to avoid transcription errors. Hollon said the hospital system changed the culture and encouraged providers regardless of rank to speak up before an error was made.
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Signature Healthcare reduced serious patient errors by 90 percent over two years, and employee injuries dropped by a similar amount over four years, Hollon said.
The Betsy Lehman Center is seeking $3.5 million in next year’s state budget to begin implementing the road map, including the software pilot program. Lawmakers should agree.
Even if the road map moves forward, the results will not be instantaneous. Fain estimates a culture shift of this magnitude will take five to 10 years. That’s all the more reason to start immediately.
Editorials represent the views of the Boston Globe Editorial Board. Follow us on Twitter at @GlobeOpinion.
