Betsy Lehman Center Re-Launches With Focus on Patient Safety
The Betsy Lehman Center for Patient Safety and Medical Error Reduction held an event at the JFK Library and Museum on Tuesday both to mark the 20th anniversary of the death of Betsy Lehman due to a massive chemotherapy overdose and to introduce the newly constituted Betsy Lehman Center, which was moved from the Department of Public Health to the Center for Health Information and Analysis in 2012. The day started off with remarks from Betsy Lehman’s two daughters and a video which you can view on the meeting's website, chiamass.gov/zeroharm. All event materials are also on the website.
The event featured two panels of speakers. The morning panel included Eric Schneider from RAND Corp., Jill Rosenthal from the National Academy for State Health Policy, and Robert Blendon from Harvard. All three of them had been commissioned by the Center to do research on patient safety and they presented the research results. Dr. Schneider’s research looked at the state of patient safety in Massachusetts and opportunities for improvement. He said that most patient safety advances have taken place in the hospital setting and the leading areas of risk are infections, medication errors, surgical risks, falls and pressure ulcers. Among a list of risks related to organizational characteristics were a lack of a patient safety culture, a failure to provider patient-centered care and to engage patients and families, and a lack of a leadership focus on patient safety. The areas he listed or future work include coordination of care, decreasing diagnostic errors, and gathering data on safety in settings outside of the hospital.
Ms. Rosenthal talked about adverse event reporting systems across the country. She said that 26 states and the District of Columbia have adverse event reporting systems, a number that has not changed since 2007. It is hard to make comparisons across states because of differences in the systems and in what is reported and how it is reported. She suggested integrating patient safety efforts into delivery system reports and evaluating reporting systems.
Mr. Blendon gave an overview of the results of survey on the public’s view of medical error in MA. Some results include: ¼ of MA residents have been personally involved in a medical error in the past 5 years, the most common error was misdiagnosis, over half of those experiencing an error believe it was the result of a mistake made by an individual provider and not by the institution where they work, about half of those experiencing an error reported it to someone else (mostly to health care providers and in very few cases to a government agency), two-thirds of those who didn’t report an error said it was because they didn’t think it would do any good, and about one-third of residents say that medical errors are a serious problem. In response to the question of what should change in Massachusetts, Mr. Blendon said that he would want more information for consumers on what an injured patient should do, how a patient can report an injury and to whom, and what will happen after they make the report.
The afternoon panel featured representatives from various sectors of the health care system, including a patient who is a Patient and Family Advisory Council (PFAC) member at Baystate Medical Center and who sits on the hospital’s patient safety committee. Among this group, topics that came up included the need for better communication with patients and families, including shared decision-making and transparency of information, the need for improved communication between health care providers, the importance of a team-based approach in general and also in particular in the area of behavioral health care, and the importance of moving from a blame culture to one focused on changing systems to reduce errors.
In between the two panels, Senator Richard Moore was honored for his work in health care and patient safety and his leadership in establishing the Betsy Lehman Center. Barbara Fain, the executive director of the Center, closed out the day talking about some of the future roles the Center may take on, including being a convener of health care entities working together on improving patient safety, a place to aggregate and disseminate data, engaging the public in conversations and partnerships, and developing more comprehensive, coherent and transparent systems.
One topic that came up many times throughout the day was the importance of engaging patients and family members, and PFACs in particular came up multiple times. I reached out to some PFAC members who attended the event to get some of their thoughts, which are shared below:
- The importance of “purposeful partnerships” with patients and family members;
- The need for a better understanding of how to report errors and with what results;
- Patient-centered care is a key component in mitigating patient safety risk;
- Great comments from PFAC members about the importance of engaging patients and family members on institutional committees and initiatives;
- Disappointed that after 20 years more has not been accomplished in the area of standardizing policy, reporting, and practices;
- Perhaps change the terminology to advance the conversation-instead of medical error say medical opportunity;
- The public still sees the individual provider and not the system as the problem;
- Awareness among health care providers about medical errors is high but is very low among consumers;
- A big gap exists between our level of knowledge and our level of action.
- Deborah Wachenheim