Betsy Lehman, a prominent Boston Globe health reporter and mother of two young girls, died in 1994 as the result of a medical error. Her shocking and untimely death catalyzed a national movement to promote patient safety. In December of 2014, we marked the 20th anniversary of her passing and the re-establishment of the Center by directing three pieces of new, independent research on the state of patient safety in Massachusetts — what has changed over the past two decades, current challenges, and where we can go from here to ensure that health care in Massachusetts is as safe as it can possibly be.

Surveying Patient Safety

The Public’s View on Medical Error in Massachusetts

1. The Harvard School of Public Health’s study seeks to gauge the public’s familiarity and awareness of the occurrence of medical error in Massachusetts. The study finds that nearly a quarter of Massachusetts residents have experienced, either first or second hand, a medical error during the course of their treatment. Of those acknowledging the occurrence of such error, a little over half of the residents answered that they reported the error to someone else with only 9% reporting to a government agency. Despite the occurrence of medical error, only roughly a third of Massachusetts residents (35%) believe that medical error is a very serious or somewhat serious problem. The HSPH study contends that in order for substantial policy changes to occur, there needs to be an increase in the public’s awareness of the prevalence, severity, and rectifiability of such issues. 

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Rand Report Collage Final

Patient Safety in Massachusetts: Current Status and Opportunities for Improvement

2. The RAND Corporation, a nonprofit policy research firm, conducted a series of interviews with designated expert observers which revealed both risks to patient safety within the healthcare system and potential risk mitigation strategies. The report noted that approximately a fifth of all Serious Reportable Events in Massachusetts are preventable. The study notes that the state’s two primary avenues for reporting events, one through the Department of Public Health and the other via the Board of Registration in Medicine, prove to be relatively inadequate in regards to system transparency. Further, there appears to be large scale underreporting of SRE’s throughout the healthcare system. The RAND research group found that risk reported by expert observers within the interviews could be classified as either Systemic Risks – organizational capability and policy influenced associated risks – or Patient-Specific Risks. RAND found that in many instances of reported medical error, Systemic Risks appeared to be listed as contributing factors or root causes and thus contends that change at this level may prove beneficial, but not without its own associated difficulties. 

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Serious Adverse Event Reporting Map

Adverse Event Reporting in Massachusetts and Other States

3. The National Academy for State Health Policy conducted a survey study of adverse medical event reporting systems nationwide and compared their findings specifically with the system within Massachusetts. About half (26) of the states and the District of Columbia, have systems in place for reporting adverse events. The study found that following the 1999 publication of the Institute of Medicine’s report, To Err is Human, the momentum that prompted many states to implement medical error reporting systems has diminished. Of the states that have implemented reporting systems, Massachusetts is the only state which requires adverse event reporting to two distinct state agencies: the Department of Public Health and the Board of Registration in Medicine. The study indicates that adopting a model of automated and uniform reporting to the two agencies, not unlike the Pennsylvania model, could potentially streamline the process and potentially lead to an increase in overall reporting. Though underreporting of adverse events continues to remain a problem, the study notes that regulators nationwide have found what data is reported to be immensely useful to surveying the state of patient safety and that this data could be best utilized if integrated into healthcare reform activities and/or grant activities. Lastly, the National Academy recommends that state entities within the Commonwealth partner up in efforts to collaborate on research initiatives, event organization, and learning collaboratives that utilize adverse event data to better promote patient safety.  

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