Mount an effective response to a patient safety event

Medical errors and other patient safety events take place in health care settings across Massachusetts every day, despite best intentions.

The Betsy Lehman Center created a web-based Patient Safety Navigator to help Massachusetts health care providers effectively respond to adverse events that occur in the course of clinical care by providing usable tools to understand how to communicate about, analyze the causes of, and report these incidents.

The purpose of the Navigator

In 2015, we started to "map" providers' reporting obligations for adverse clinical events to better understand the scope of health care safety information currently collected. What we found was a regulatory landscape that was critical to monitoring patient safety, but also complex. So we set out to add clarity to these reporting processes by building and hosting the Navigator. Our goal is to boost the recognition and disclosure of the most serious breaches of patient safety in the interest of enhancing the opportunity for organizations and providers across the state - individually and collectively - to learn from these mistakes.

What you will find here

  • The Plan module helps providers and managers focus efforts on preventing patient harm events. The module can be used to bolster or build a patient safety plan at health care organizations and practices, especially smaller ones that are new to patient safety planning. It is divided into specific components, such as coordination, objectives, and communication, each of which provides concrete tips and tools. This module contains information adapted from extensive work done by the Massachusetts Health Care Quality and Cost Council. 
  • The Report module helps providers who experience an adverse event to classify it, learn which agency to notify, and quickly access information on when and how to report the event. We developed this information through extensive research into both state and federal patient safety regulations, ongoing dialogue and vetting with other state agencies, iterative web development and design, and user testing and feedback sessions with health care facility staff.
  • The Communicate module offers guidance for talking with patients and their families – as well as having important internal conversations – in the aftermath of an adverse event. This material was developed in partnership with two organizations that have expertise working with health care organizations and families that have been affected by a patient harm incident.
  • The Analyze module is a Web adaptation of a guide developed by the National Patient Safety Foundation to improve provider organizations' ability to fully understand the root causes of an adverse event and take meaningful actions to prevent a recurrence. It contains step-by-step instructions and a suite of useful tools. The goal is to help providers learn from both adverse events and "close calls" that were caught before they reached the patient – all in the interest of boosting the safety of systems used to deliver care.