Massachusetts has established an ambitious agenda to contain cost and improve the quality of health care across the state through transparency, efficiency and innovation. But what is the value of a more efficient health care delivery system if patients are at significant risk of being harmed by mistakes made in their health care?
A staggering number of Massachusetts residents — almost one in four — reported having experienced a medical error in the past five years in a survey conducted by the Harvard School of Public Health and released earlier this month. Well over half of those errors resulted in serious health consequences.
These numbers are consistent with national studies that estimate up to 440,000 preventable deaths per year associated with hospital stays alone. As noted at a US Senate hearing in July, this is the equivalent of three jumbo jet crashes per day. But unlike plane crashes, medical error happens to individuals, quietly and away from the public’s view.
The Massachusetts Legislature recently recognized the need to include patient safety in the cost and quality equation when it reestablished the Betsy Lehman Center for Patient Safety and Medical Error Reduction as an independent, nonregulatory state agency. The center bears the name of a Boston Globe health reporter who died from an overdose of chemotherapy during treatment for breast cancer 20 years ago. The story of Betsy’s death, investigated and reported by her colleagues, helped catalyze a focus on patient safety here and nationally.
But two decades later, information simply does not exist to answer the most basic of questions: how many Massachusetts patients are being harmed by medical error today; where are the biggest areas of risk; what are the trends — is the problem getting better or worse?
At the center, we saw this inability to even describe the current state of affairs as a problem. If you don’t know where you are, it is hard to chart a course. So we commissioned three pieces of independent research, including the Harvard survey, to begin to develop an evidence base about patient safety in Massachusetts today.
In addition to the sobering finding about the large numbers of residents affected by medical error, here is some of what we learned:
Progress. Awareness of medical error and understanding of its root causes is at an all-time high among health care providers, particularly in hospitals. This awareness has led to development of a multitude of proven strategies that, if implemented, could prevent most of these errors from occurring. Indeed, a recent federal analysis of national data found a significant decline in hospital-associated harm between 2011 and 2013, including 50,000 fewer patient deaths.
Ongoing challenges. Nearly all of the advances in patient safety have been confined to hospitals, barely reaching the outpatient physician practices, dialysis centers, pharmacies, ambulatory surgical centers, and nursing homes where likely half of all serious medical harm now occurs. And among hospitals, investment in systems to prevent error and fostering of a patient safety culture has varied considerably depending on interest and commitment at the executive and board levels. Communications systems that have not kept pace with the increasing complexities of health care also make it harder to get things right, particularly when patients see multiple providers in multiple places.
Barriers to change. When asked to identify the greatest present risks to patient safety, many providers cited the lack of relevant data about medical error — or what’s going on under their own feet — as a risk in and of itself. From the consumer standpoint, one in three residents sees medical error as a somewhat or very serious problem in Massachusetts. Although this reflects an emerging public awareness of medical error as a threat to public health, the urgency needed to drive major change is still missing.
Now that we have a better idea of where we are, how do we move forward? For starters, we need to change the conversation. One way to do that is to be sure it is well-informed.
The Betsy Lehman Center will convene a process to map out a comprehensive, coherent, and transparent system for gathering and sharing essential information about the status of patient safety in the Commonwealth. The center also will work on new approaches for aggregating, curating, and disseminating actionable information to providers and consumers.
Another way to change the conversation is to bring new voices to the table — including those of consumers. What set Betsy Lehman’s journalism apart was her belief that the public could become active participants in health care. A guiding principle of the center will be to engage consumers in meaningful ways from creating new mechanisms to gather information about their experiences in the health care system to the development of policies to promote patient safety.
Before Massachusetts can meet its ambitious cost and quality reform goals, the health care delivered across all care settings throughout the state must be fundamentally safe. Financial costs to the system aside, the human costs of medical error demand that we set a bold aim of eliminating harm in the Commonwealth. This kind of big thinking, combined with our uniquely collaborative health policy environment, has allowed Massachusetts to meet seemingly impossible challenges in the past. Nothing short of those efforts is what we must commit to now.Barbara Fain is the executive director of the Betsy Lehman Center.