With small investment, medical errors can be prevented

State funding for promising safety improvement work could play crucial role

WE NEED to invest in ways to reduce medical errors and improve patient safety. The House rejected an amendment that would have provided $3.5 million to address these problems, so now the challenge falls to the Senate.

The bill would provide the money to the Betsy Lehman Center to help educate the health care workforce on safety, launch a pilot program to support safety improvement systems in outpatient offices practices, and create an eight-hospital software demonstration project to automatically detect patient safety events and prompt hospital staff to address those detected threats in a timely way.

State government has tended to be slow to force our health care system to own up to the reality that too often it fails to protect patients adequately from preventable harms.  While we are a state that takes pride in saying that we have a world class health care system, when it comes to patient safety and preventing harm from medical errors, we still have a long way to go.   A national patient safety organization, the Leapfrog Group, currently rates our state’s hospitals as tenth in the country in terms of the proportion of institutions that are doing what they should to make care safer.

Sadly, medical errors are too common.   A recent New England Journal of Medicine study reviewing care at 11 Massachusetts hospitals in 2018 found that 7 percent of all hospital admissions contained a preventable adverse event—most often, errors connected to medication or some sort of medical or surgical procedure, or an untoward occurrence such as a patient fall, skin pressure ulcers, or health-care-associated infections.  That means as many as 55,000 patients admitted to Massachusetts hospitals each year experience a preventable harm event.

And some of these events are deadly, as we recently read about one such tragic case at Boston Children’s Hospital.

We are fortunate to have a government agency, the Betsy Lehman Center, whose mission is to improve patient safety. It came into existence following the outcry that surrounded the death of Boston Globe reporter Betsy Lehman, who died in 1994 after receiving an overdose of chemotherapy drugs at Dana Farber Cancer Center.

During the COVID era—when many suggest that patient safety issues have only worsened–the agency has been working with representatives from 36 stakeholder groups to develop a Roadmap to Health Care Safety for Massachusetts . The document is a strategic plan organized around five goals that should help guide providers, patients, payers, policymakers, regulators, and the public to focus on adopting key strategies and action steps that are needed to help make patient care safer in our state.

This brings me back to the hoped for Senate budget provision and, in particular, its funding for an eight-hospital demonstration of an automated safety event detection system that not only identifies these events on a timely basis but directly supports hospitals’ safety improvement work.  Provider organizations, hospitals included, typically rely on caregivers to detect and report safety events. This approach results in vast under-reporting of medical errors as well as poor insights into underlying safety risks.

Now, thanks to advances in health care information technology, software can run behind a hospital’s electronic medical records system, detect adverse events in real time, and generate alerts for review by clinical experts. Reliable information is fed back to the appropriate staff who can take steps to prevent similar events from occurring in the future, and sometimes even intervene to stop an evolving harm to an individual patient.   Automated event detection systems are now being used by hundreds of hospitals in other states across the US. They have been proven effective at detecting large numbers of safety events, identifying patterns, and enabling a response that reduces the incidence of future patient harm.

But uptake of these systems is happening through individual hospital initiative, and there has been no attempt to support broad adoption or to aggregate data to understand patient safety trends at a state level. A pilot in a diverse group of Massachusetts hospitals – with technical assistance to help them apply the data to improve their safety culture and operations – could tell us if the frequency and severity of preventable patient harms can be sustainably reduced.

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For very small dollars, deciding to go forward with this demonstration effort carries with it the promise of learning something that could then be implemented widely to achieve big gains in patient safety. It seems to me the Senate would be wise to include such a provision in its final version of the state’s budget, with the hope that the House would then adopt it during the legislative reconciliation process.

This demonstration could begin before the end of the year. If successful, it could be scaled throughout our state’s entire hospital sector and ultimately to other kinds of provider settings. That would represent a true breakthrough in patient safety.

Paul A. Hattis is a senior fellow at the Lown Institute.