December 12, 2023

Patient Safety Beat

Patient safety news and progress in Massachusetts.

From the Executive Director

One of Massachusetts’ most notable assets is the willingness of leaders from all sectors to come together to tackle intractable public policy challenges. Since 2019, the Betsy Lehman Center has convened a broad consortium to chart a new approach to achieve safety in health care. In April, we unveiled the result of our work, the Roadmap to Health Care Safety for Massachusetts.

There is, of course, much more work to be done in 2024 as we move on to implementation and investment. I’m pleased that we are doing it together.

When we released the Roadmap at the Massachusetts Health Policy Forum, we led with a video, “Voices from the Frontlines of Health Care Safety” that serves as inspiration for what we all do each day.

In our 5 top articles from Patient Safety Beat this year, you’ll see many references to the safety challenges we face today as well as concrete steps to advance the Roadmap’s five goals on leadership and governance, continuous improvement, patient and family engagement and support, workforce well-being, and measurement and transparency.

I hope you have a restful holiday with family and friends and look forward to our collective accomplishments in the coming year.

Best wishes,
Barbara Fain


Broad support for new Roadmap to Health Care Safety voiced at Massachusetts Health Policy Forum

The Roadmap defines goals, strategies and action steps to guide a statewide effort to prioritize the safety of patients and the health care workforce. At the Forum, an initiative of The Heller School for Social Policy and Management at Brandeis University, the state’s Undersecretary for Health, Kiame Mahaniah, M.D. told nearly 200 attendees that safety must be “at the center of health care."

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Real-time EHR monitoring yields strong, actionable data on health care safety

Early adopters in other states have made dramatic gains in safety by monitoring inpatients’ electronic health records for signals of harm events. This automated approach, which enables real-time identification of hundreds of known safety “triggers,” will be the focus of a voluntary pilot in Massachusetts hospitals to be launched next year.

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Q&A: Three experts on the SafeCare study and its implications for future patient safety action

David Bates, M.D.; Patricia Folcarelli, Ph.D., R.N.; and Elizabeth Mort, M.D., discuss findings from a comprehensive assessment of adverse events in 11 Massachusetts hospitals. Talking with Patient Safety Beat, the co-authors discuss automated surveillance systems, embedding quality and safety goals in management structures, supporting the workforce and more.

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Leaders discuss ways to address structural inequities that pose a risk to safety

Patient Safety Beat explores the role of health equity in safety through conversations with Deborah Washington, R.N., Ph.D.; Karthik Sivashanker, M.D., M.P.H.; Matilde Castiel, M.D.; and Milagros Abreu, M.D., M.P.H. Each shares thoughts on addressing inequities inherent in long-standing organizational policies, procedures and norms.

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PFACs emerge from the pandemic ready to enhance the patient voice at hospitals and ACOs

Patient and Family Advisory Councils are transitioning away from COVID impacts to once again address a broader set of challenges, including health inequities. The PFAC at Cooley Dickinson Hospital in Northampton works with local social service agencies and colleges to help expand its membership. The state’s new Roadmap to Health Care Safety calls for strengthening the role PFACs play in improving care across the state.

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Patient Safety Beat is published by the Betsy Lehman Center, a Massachusetts state agency that supports providers, patients and policymakers working together to advance the safety and quality of health care.

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