Every year, the state receives reports of more than 1,000 serious reportable events (SREs) from hospitals and ambulatory surgery centers, and providers have asked the state to share analysis, event details, and corrective measures taken by peer institutions to prevent recurrence. In 2014, 13 percent of surgical SREs reported occurred to patients undergoing cataract surgery, the most common surgical procedure in the U.S. As a result, we convened an expert panel of providers and patients to look into why these errors occurred and what could be done to prevent more of them. Read the panel’s full report here.

Early results are encouraging. Over 40 percent of Massachusetts cataract surgeons surveyed acted on the panel’s recommendations and more than 75 percent of surveyed ophthalmologists found the panel’s findings to be “somewhat” or “mostly” consistent with their own observations and experience. View the full survey results here. Not everyone agreed with the panel’s conclusions, particularly around choice of anesthesia technique. And responses to surveys are not as reliable as measuring outcomes. We may not know the real impact of the panel’s work for some time.

Here are a few takeaways that will inform our work going forward and may help you in yours:

1) We can learn from imperfect data: Serious Reportable Events (SREs) are under-reported in Massachusetts. But unlike other datasets that are more complete, these reports offer narratives that describe how and why adverse events occurred. Expert review of these narratives can help highlight where risks exist and how providers can address them. You can do the same in your organization even if the data are limited.

2) Stories from peers are persuasive: We conducted a series of confidential conversations with cataract surgery providers who had experience with adverse events. All were deeply affected and eager to share with others what they had learned. Leverage the experience of people in your organization to ‘spread the word’ about how, what and why to make changes in their approaches to patient care to improve safety.

3) Share safety messages via many channels and in many formats: Information won’t have much influence if the target audience doesn’t read it. Health care staff get their information in a variety of ways and we continue to share the report’s findings with providers through peer-reviewed journal articles, the Web, mainstream media outlets, Grand Rounds presentations, targeted mailings and online webinars.

4) Providers need more than information—they need tools to act: We compiled relevant tools from across the country to help cataract surgery practices implement the panel’s recommendations. Add tools staff can use to any patient safety improvement project you undertake.

5) Involve patients in safety improvement work: Patient representatives were critical to our expert panel’s function and perspective. Consider involving patients in your safety planning and discussions. They can be among your greatest assets.