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Medical errors in Mass. still common, study finds

State center resets focus on safety, care

The case of Betsy Lehman, a Boston Globe health reporter who died in 1994 after receiving a massive overdose of chemotherapy at a prestigious Boston cancer center, galvanized health leaders to reduce medical errors.

But two decades later, nearly one-quarter of Massachusetts residents say they, or someone close to them, experienced a mistake in their medical care during the past five years, according to a survey released Tuesday. And about half of those who reported a mistake said the error resulted in serious health consequences.

The poll of 1,224 residents by Harvard School of Public Health researchers found that many people did not report the medical mistakes, often because they did not believe it would do any good, or they did not know how to report it.


The findings are in a trove of new reports commissioned by an agency created in Lehman’s memory, the Betsy Lehman Center for Patient Safety and Medical Error Reduction.

“When you are trying to reduce incidents, and 20 years later you still have a significant number of people who report a significant event, it sets off concerns,” said Robert Blendon, a Harvard professor of health policy and political analysis, and the poll’s director.

Lehman, a 39-year-old wife and mother of two who had been undergoing breast cancer treatment, was given a fourfold overdose of an anticancer drug, despite questions raised by her husband at the time about her horrific symptoms. The mistake was not detected until a routine review months after her death.

In 1999, a landmark report from the Institute of Medicine concluded that as many as 98,000 people were dying in hospitals each year because of preventable medical errors.

A study released Tuesday from the federal government suggests some progress in stemming the tide. An estimated 50,000 fewer hospital patients nationwide died in the past three years, largely from decreases in medication errors and pressure sores, compared with the rates in 2010, the Department of Health and Human Services analysis concluded.


The Lehman center was launched in 2004 as part of the state’s Executive Office of Health and Human Services, and produced guidelines to reduce patient harm in weight-loss surgery and to control infections during treatment in medical facilities. But it struggled for funding, then fell victim to recession budget cuts and went dark in 2010.

It was reestablished last year because of a push by state Senator Richard T. Moore, former chairman of the Joint Committee on Health Care Financing, to improve quality and reduce health care costs. The center is now an independent agency within the state’s Center for Health Information and Analysis, and draws its $970,000 annual budget from a fee assessed on hospitals and insurers.

Emily (left) and Laura Distel, daughters of the late Betsy Lehman, at the JFK Library on Tuesday.HARRY O. LOHR JR./Harry O. Lohr Jr.

“We wanted it to be independent, to give critical analysis,” Moore said.

The center’s new director, Barbara Fain, quickly found creating a plan for action was challenging. Despite an avalanche of data, little was actually known about patient safety in the state, she concluded.

Most of the data collected and reported by the state regarding serious medical errors come from acute-care hospitals and surgical centers. But changes in the way the figures have been collected since 2008 make it hard to pinpoint whether patient safety has improved or stalled. “How many patients in Massachusetts are being harmed by medical errors today? Where are the trends? Where are the hot spots? Is it getting better? If you don’t know where you are, it’s hard to know where to go,” Fain said.


To help the center plot a course, Fain commissioned Blendon’s study and two others, also released Tuesday, that found while progress has been made in reducing patient harm in Massachusetts, yawning gaps persist. Researchers detailed their findings during an event at the John F. Kennedy Library, as the Lehman center renewed its mission.

A report from RAND Health found improvements in preventing wrong-side surgeries — such as mistakenly operating on the left arm instead of the right, for example — and detailed a reduction in falls among elderly patients and medication errors. But many of the 41 specialists interviewed by RAND believe problems persist in each of those categories.

RAND also found the push to replace patients’ paper files with electronic records holds promise, but facilities too often use different systems that don’t communicate with each other, placing patients at risk when critical information is missed.

Another study, by the National Academy for State Health Policy, found 26 states have systems that monitor adverse medical events, but the number has not increased since 2007. While regulators said they believe the systems yield valuable information, the ability to gauge overall trends in patient safety is limited. That is because most states have not integrated their monitoring systems into broader initiatives to improve quality and reduce medical costs, researchers found.

The study by Harvard’s Blendon found that only about one-third of Massachusetts residents surveyed said they had ever searched for information about the safety or quality of medical care provided by physicians or hospitals. And two-thirds said they did not regard medical errors as a serious concern, or weren’t sure.


Dr. Donald Berwick, a patient safety specialist who founded the Cambridge-based Institute for Healthcare Improvement, said he found it troubling so many residents reported experiencing a recent medical error with serious health consequences, yet most did not regard it as serious.

“The delivery of medical care is a complex enterprise, and people are intimidated by their ability to judge the quality and safety of what happened to them,” said Berwick, who lost a bid for the Democratic nomination for governor this year.

While much of the attention has focused on improving hospital quality, Blendon’s surveys have found patients typically do not regard the issue as one of problem institutions, but of their experiences with individual doctors and nurses.

Blendon said that underscores the need for patient safety initiatives that share the stories of everyday people to truly resonate with the public.

Betsy Lehman “was a real person who brought a nation into this issue,” Blendon said. “It wasn’t a statistical report.”


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Kay Lazar can be reached at Kay.Lazar@globe.com .