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As we prepared to send this newsletter to you, we received the sad news that Lucian Leape, M.D., had passed away on June 30. Lucian was a steadfast supporter of the Betsy Lehman Center and mentor and colleague to so many in the patient safety community.
In an issue later this summer, we will review Lucian’s invaluable contributions as a physician and researcher, as well as his role as a pioneering leader and moral compass of the patient safety movement. In the meantime, you might want to read the obituary from the New York Times.
We extend our condolences to his family and his numerous friends and colleagues.
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While working to improve communication, teamwork and shared decision-making, nurses at The Birthplace at Baystate Medical Center in Greenfield saw something concerning in their data from the patient surveys. Though nearly two-thirds with private health insurance felt that their health care team "understood my background, home life and health history," that was true for only 33% of MassHealth members.
As a result, The Birthplace started to assess health-related social needs of patients giving birth and created guides to local resources to address those needs. Subsequent surveys show improvement in the number of MassHealth members indicating they feel understood, and the number of patients asking for help finding resources is growing.
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The Betsy Lehman Center is making it easier for hospital Patient and Family Advisory Councils to generate annual reports. A new template is available now, well in advance of the October 1 deadline. It offers greater flexibility to describe key goals, accomplishments and impact, as well as a simplified format for describing the PFAC’s structure, meetings, and membership.
The 2025 template will enable the Center to produce an annual, aggregated report with a comprehensive picture of PFACs’ accomplishments and challenges across the state. The Center will also generate summaries of the information submitted by PFACs so they can share key elements of their work with hospital leaders, patients and others in the community.
Read the story
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An updated Massachusetts Primary Care Dashboard released this month tracks the health of the state’s network of primary care offerings by measuring four domains: finance, capacity, performance and equity. A collaboration between the Center for Health Information and Analysis and Massachusetts Health Quality Partners, the dashboard shows that the percentage of primary care physicians continues to decline, and patients find it is increasingly difficult to find primary care when they need it.
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How to Succeed at Failing, from the Freakonomics Radio podcast, features Patients for Patient Safety US founder Carole Hemmelgarn, whose daughter died from medical error; Harvard Professor Amy C. Edmondson; research psychologist Gary Klein; and others. They discuss the reality of human error, ways to prevent it from causing harm, and even how to capitalize on its opportunities. Originally released in 2023, facts and figures in the episode have been updated.
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The June newsletter from the Patient Safety Authority offers strategies to prevent fivefold wrong-dose errors associated with the use of U-500 insulin. Reports recently submitted to the Pennsylvania Patient Safety Reporting System document errors that could lead to life-threatening hypoglycemia or hyperglycemia.
| | | |  | Teamwork and social capital: The secrets to building a culture of high reliability. Tejal Gandhi, M.D., M.P.H., Press Ganey’s Chief Safety and Transformation Officer, talks with Cambridge Health Alliance’s Chief Quality Officer Maren Batalden, M.D., M.P.H., and Associate Chief Quality and Patient Safety Officer Taruna R. Banerjee, M.P.H., about how social capital and teamwork support high reliability and safety culture. Register here | | | | | The Power—and Consequences—of Language After Patient Harm. Evan Benjamin, M.D., and Carole Hemmelgarn discuss the impact of language on patients and families after medical harm in a webinar hosted by the Collaborative for Accountability and Improvement. Register here | | | | | Patient and Family Advisory Councils: Uplifting the Patient Voice for CMS Structural Measure Domain 5. Discover actionable strategies for strengthening patient and family engagement in your organization. From the Massachusetts Health & Hospital Association with Jane Powers, Director of PFACs at the Betsy Lehman Center, and Aideen Snell, Director of Patient Experience at Cambridge Health Alliance. Register here | | | | The Betsy Lehman Center is a Massachusetts state agency that supports providers, patients and policymakers working together to advance the safety and quality of health care. | | | | |
