To address inequities in maternal health, the Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN) is working with more than 20 hospitals in the state to adopt its maternal equity bundle. The bundle is a set of evidence-based actions to make birth safer and improve outcomes for all people giving birth while addressing racial and ethnic disparities.
 
PNQIN’s initiative is based on the Alliance for Innovation on Maternal Health’s (AIM) maternal equity framework, used to combat the rise in maternal morbidity and mortality nationwide. AIM also focuses on medical complications of pregnancy, such as hypertension, cardiac conditions and substance use disorder.
 
In addition to PNQIN, which provides guidance, education and technical assistance to participating hospitals, Ariadne Labs’ TeamBirth is helping hospitals implement the equity bundle, adapting training and guidance to the needs of each community and facility. The Betsy Lehman Center is also a partner, collecting and analyzing data integral to tracking progress in improved maternal outcomes. All birthing hospitals in the state are invited to join the effort.

Increasing numbers of patients rely on medical devices used at home, but they may not know when manufacturers issue safety recalls, as noted by ECRI on this year’s Top 10 Health Technology Hazards list. Manufacturers and distributors are rarely in direct communication with patients, and physicians may not know exactly which devices their patients are using.

Even patients with good access to information may have trouble getting prompt and satisfactory help, as ECRI’s Ismael Cordero described on a recent webcast. Developing an effective recall process for these devices will require action coordinated across multiple stakeholders, including manufacturers, providers and the FDA, as well as patients.
Massachusetts Health Policy Forum to focus on statewide Roadmap to Healthcare Safety

Brandeis University’s Massachusetts Health Policy Forum will feature the release of the "Roadmap to Healthcare Safety for Massachusetts” at its first in-person event since the COVID-19 outbreak. The Roadmap to Safety was produced by the Massachusetts Healthcare Safety and Quality Consortium, a collaboration of 40 stakeholder organizations led by the Betsy Lehman Center. It defines a strategic plan, policy proposals, and action steps to accelerate health care safety improvement across the state’s continuum of care. This half-day event will take place at the Omni Parker House in Boston on April 26 from 8 to 11:30 a.m. Registration is free and will be available in mid-March. Save the date!

  • Hospitals are banding together to implement a common set of principles to protect health care workers from violence in the workplace. The United Code of Conduct is part of a new report from the Massachusetts Health & Hospital Association that sheds light on the increase of violent incidents in facilities across the state.
  • The Center for Health Information and Analysis, in partnership with Massachusetts Health Quality Partners, offers a new dashboard to monitor the health of the primary care system in the Commonwealth. It will track the key areas of finance, capacity, performance and equity.  
  • A new Serious Illness Messaging Toolkit includes stories, worksheets, quick start guides and more to help organizations engage the public on the needs of people with serious illnesses. The toolkit is based on research from the Massachusetts Coalition for Serious Illness Care. 
  • A case study from Brigham and Women’s Hospital finds that integrating the I-PASS patient handoff tool into its electronic health record improved efficiency and lowered inpatient mortality, without causing delays when admitting patients to the ICU.
Upcoming events
March 2
12 p.m.
Understanding Documentation Risks in Malpractice Cases. In this live webinar, CRICO will provide an overview of safety risks during documentation, such as using copy and paste in medical records, with case examples and mitigation strategies. Register here
March 15 - 16
Pulse Center for Patient Safety Education & Advocacy's Annual Symposium. The Current Landscape of Patient Safety: Where We’ve Been, Where We’re Going is a virtual event featuring patient safety experts from across the U.S. and a keynote from Tejal Gandhi, MD, Chief Safety and Transformation Officer at Press Ganey. Learn more
March 16
2 p.m.
Implementing a Clinician and Staff Peer Support Program. The Betsy Lehman Center peer support team discusses how to implement and sustain a robust peer support program in this webinar from the Collaborative for Accountability and Improvement. Register here
March 29
10 a.m.
Building a Robust Health Care Workforce in Massachusetts. The Health Policy Commission will release findings from its upcoming report on the impact of COVID-19 on the health care workforce. Learn more
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.