TENS OF THOUSANDS of people are harmed every year in Massachusetts due to preventable medical errors, according to Barbara Fain, head of the Betsy Lehman Center for Patient Safety.
“Most people reasonably assume that the necessary safeguards exist and aren’t aware that they’re often lacking,” Fain said on The Codcast. “There’s never been any real strong grassroots pressure to prioritize safety in health care. We have a lot of other priorities in health care, but safety is not top of the list.”
The Betsy Lehman Center is a state agency that conducts research, data analysis, and programming to improve patient safety in hospitals and other health care facilities. The center is named after Betsy Lehman, a former Boston Globe reporter who died in 1994 after receiving four times the intended dose of a chemotherapy drug while she was being treated for breast cancer.
After Lehman died, public awareness around medical errors spiked, Fain noted, but three decades later the issue has lost visibility and strategies to mitigate patient harm are not always in place.
“The bottom line is that, despite all this work over the past couple of decades, health care is still not anywhere near as safe as it could or should be,” said Fain.
All too often, she said, mistakes are not tracked. “When bad things happen to individual patients, they tend to happen behind closed doors,” Fain said. “And so there’s just this low visibility, low awareness problem that is problematic.”
To address the lack of data on medical errors, the Lehman Center released a report in 2019 containing two major studies in Massachusetts. The first one analyzed health insurance claims data from the year 2013 and found that there were 62,000 cases of medical errors in just that one year. According to Fain, this is a very conservative estimate of the number of “harm events” and doesn’t include preventable but hard to categorize errors such as falls or delays in critical diagnoses.
The Lehman Center ran a second study from 2017 to 2018 to gauge the impact of medical errors on patients’ lives. A series of phone surveys and follow-up interviews with Massachusetts residents revealed that one in five people said they or a family member had experienced a medical error.
“The impacts of these events on patients and families, they’re tremendous,” said Fain. “People report just incredibly long-lasting physical, emotional, financial tolls.”
Medical errors can erode trust in the health care system for people, according to Fain.
“One of the most troubling aspects of what we heard from patients and families was that these events caused them to lose trust in the health care system, particularly when providers failed to communicate openly about these mistakes that had harmed them. And that was usually the case,” Fain said.
The Lehman Center has a roadmap for improving patient safety. They have recommendations on how to improve the culture and operations in health care spaces that privilege safety. For example, they hope to create a statewide health care safety curriculum and they advocate for health care safety to be integrated into training for all health care professionals.
The center has also proposed a pilot program that would leverage technology to analyze hospital electronic health records to automatically detect a wide range of patient harm events in real time. The idea is to improve data collection and help provide feedback to health care providers in one fell swoop. The center would also provide hospitals with coaching on how to gather the data, apply the data, and fix the underlying risks that cause harm events. This approach, according to Fain, has shown dramatic reductions in patient harm for early adopters elsewhere in the country.
The pilot is just now getting off the ground, with a task force seeking to pick a vendor for the technology and the hospitals that will participate. Additional funding will be needed to get the program up and running. “We do think that these programs show great promise, and that’s why we’re making the investment,” said Fain.