Patient Safety in the Commonwealth of Massachusetts

Patient Safety in the Commonwealth of Massachusetts: Current Status and Opportunities for Improvement

Eric C. Schneider
M. Susan Ridgely
Dmitry Khodyakov
Lauren E. Hunter
Zachary Predmore
Robert S. Rudin
Copyright Date: 2014
Published by: RAND Corporation
Pages: 62
https://www.jstor.org/stable/10.7249/j.ctt14bs3bv
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  • Book Info
    Patient Safety in the Commonwealth of Massachusetts
    Book Description:

    In a RAND study about the landscape of patient safety in Massachusetts, researchers interviewed expert observers (patients, health care leaders, academic experts, advocates, and others) about progress to date and future opportunities to produce safer patient care. This report summarizes the results of the interviews and suggests several questions that could guide the design of an organized effort to improve patient safety in Massachusetts.

    eISBN: 978-0-8330-8928-1
    Subjects: Public Health, Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Table of Contents
    (pp. iii-iii)
  3. Table
    (pp. iv-iv)
  4. Acknowledgments
    (pp. v-v)
  5. Abbreviations
    (pp. vi-vi)
  6. Introduction
    (pp. 1-3)

    Twenty years ago, Betsy Lehman, an award–winning health columnist for theBoston Globe, received a massive overdose of chemotherapy at the Dana–Farber Cancer Institute, one of the nation’s most prestigious cancer hospitals. Tragically, the error that led to her untimely death went unnoticed until several months later, when it was discovered at the time of a review of clinical trial data (Altman, 1995). Otherwise, it might never have come to light. At about the same time, a group of investigators at Harvard Medical School documented that errors like the one that took Betsy Lehman’s life were far from...

  7. Methods Used to Develop This Report
    (pp. 3-3)

    RAND conducted a set of interviews with expert observers having relevant expertise in health care safety. Appendix B contains details of our approach to data collection and analysis. Before conducting the interviews, RAND reviewed published literature, websites, newspaper articles, and other documents relevant to patient safety in Massachusetts. The purpose was to identify quantitative estimates about the safety of care; review the status of Massachusetts’ adverse event reporting systems; and identify potential expert observers for interview. Individuals approached for interview included representative patients and caregivers, academic experts, leaders of health care delivery organizations, independent safety and quality advocacy organizations, and...

  8. What Kinds of Patient Safety Risks Did Expert Observers Identify?
    (pp. 3-13)

    We asked expert observers to reflect on the changing profile of patient safety risks over time. We asked them about the safety risks known 20 years ago that have been addressed and in some cases reduced over time, persistent risks that have been identified and addressed, but are still important concerns, and newly apparent risks that have become more visible in recent years as patient safety research and practice have advanced.

    In general, the Massachusetts expert observers responding to a general question about safety risks spoke aboutpatient–specific safety risks(errors and adverse events in the care of individual...

  9. Looking Ahead: Opportunities to Advance the Safety Agenda in Massachusetts
    (pp. 13-15)

    Our study was commissioned to obtain confidential and anonymous input from a cross–section of expert observers about potential opportunities for an organization like the Betsy Lehman Center for Patient Safety and Medical Error Reduction to pursue initiatives that can advance patient safety in Massachusetts. As the results suggest, expert observers identified several opportunities. Some identified areas that need more focus, such as nonhospital settings, while others suggested programmatic actions, such as convening expert observers or disseminating evidence–based information. A few expert observers sounded a cautionary note. The unmet needs in patient safety are substantial, but the “niche” for...

  10. Conclusion: Questions About the Commonwealth’s Future Patient Safety Efforts
    (pp. 15-17)

    In the 20 years since Betsy Lehman’s tragic death from a medical error, Massachusetts has been an intellectual incubator for new knowledge about patient safety, important demonstration projects, and new tools that can mitigate safety risks (Forster et al., 2003; Weissman et al., 2008; Bates et al., 1998). These tools have been taken up in federal legislation and in several organizations. It is less clear whether progress has been made in making care safer for the citizens of the Commonwealth. The challenge of documenting progress on patient safety is not unique to Massachusetts. Several observers have suggested that evidence that...

  11. References
    (pp. 18-19)
  12. Appendix A: Qualitative Interview Results
    (pp. A-1-A-34)
  13. Appendix B. Research Methods
    (pp. B-1-B-3)