May 2016


		May 2016

Up Front

Cataract surgery errors spur a new collaborative model for improving safety


			A multi-disciplinary panel that analyzed an unusual cluster of cataract surgery errors in Massachusetts unveiled its findings mid-May. But the 46-page report, filled with actionable recommendations, is only the beginning of the impact on patient safety. Just as important, participants say, was the process that brought them to that result. Click for more


	FIVE QUESTIONS WITH ... Lucian L. Leape
	Dr. Lucian Leape has devoted much of his attention to patient safety, where his research, speaking and writing helped drive the revolutionary changes in the field over the past two decades. "When you say to a physician that there's only a one-in-a-thousand chance of error, he says, 'Hey, I'm doing great. I'm 99.9 percent perfect.' They don't change unless they see some reason to, and if they don't have any complications, well, why do it?" Click for more


	Safety News

	The high cost of faulty communications Simply improving basic communications — especially among clinical staff — could make hospitals safer for patients while reducing costs from malpractice claims. That's the conclusion from a new cut of CRICO's nation-wide malpractice database, which shows lawsuits involving a staff-to-staff miscommunication are the most expensive of all. Click for more


			The loss of a fierce patient safety advocate Nancy Ridley — Betsy Lehman's Center's first director — is remembered here by one of her many friends and fans, Larry Tye, author and former Boston Globe health reporter. "Nancy was loyal to her colleagues and supervisors at the Department of Public Health," he writes, "but she was more loyal to the public she worked for and saw the press as a route to informing those citizens." Click for more

Re-engineering health care for safety

What if you could build a computer model of your current treatment process that helps you make the system better and safer? That's one tool being used by a new federally-funded learning lab that aims to improve communication between primary care providers and specialists in several Massachusetts health systems.

Click for more


	Safety in a Single Graphic

	Our expert panel's report on improving the safety and reliability of cataract surgery in the state is summarized in a single graphic. Click to view full graphic.


	Upcoming Events Mind the Gaps: Avoiding the risks of communication failures in patient care sponsored by CRICO on June 9 from 8 AM - 4:30 PM at the Revere Hotel, Boston. Advanced registration fees range from $100-$250; $25 for CRICO-insured residents and fellows. Patient and Family Advisory Council Conference sponsored by Health Care for All on June 23 from 8 AM - 4 PM at Sheraton Four Points, Norwood. Registration fee is $85.00.
	Do you have a patient safety event for an upcoming issue? Please send it to us.

Just One Thing

Patient safety improvements are seldom simple. But each month, we'll bring you "just one thing" that could help boost your efforts to reduce the risk of patient harm.

Checklists aren't just for the surgical team. Researchers are experimenting with using them for a variety of medical procedures. Why not try one before delivering a diagnosis? After the history-taking, physical exam, and formation of a differential diagnosis, take a time-out and ask yourself these questions:

What else could this be?
Is there any important information I am missing?
Did I consider the inherent flaws of heuristic thinking?
Was my judgment affected by any other bias?
Is there anything that does not fit with my working diagnosis?
Do I need to make the diagnosis now, or can I wait?
What is the worst-case scenario?
What is our 'watchful waiting strategy' to make sure we follow-up, especially if the patient does not improve as expected based on the initial diagnosis?

Initial work on this list is from doctors John Ely, Mark Graber, and Patrick Croskerry and has been modified by Gordon Schiff, MD, at Brigham and Women's Hospital for this publication. Disease-specific diagnostic checklists are available as part of the clinical reasoning toolkit from the Society to Improve Diagnosis in Medicine.


	From the Director
	Welcome to the first edition of our new monthly publication! We are excited about providing important and lively stories about the roles everyone - not just the Betsy Lehman Center - plays in lowering the risks patients face in all health care settings. Yes, this month's lead story does focus on the Center's recent cataract surgery expert panel report. But it's really a narrative about a lot of people who worked together to understand one set of patient safety risks and to effect change. In that spirit, we are also dedicating our inaugural edition to the Center's dear friend and advocate, Nancy Ridley, who died last month. Her commitment to improving patient safety in the wake of Betsy Lehman's death from a medical mistake lives on in Massachusetts. Please subscribe here. And, if you have a comment or story idea for a future edition, we'd love to hear it.

Patient Safety Beat is published monthly by the Betsy Lehman Center, a state agency that uses communications, research, and data to catalyze the efforts of providers, policymakers, and consumers working toward safer health care in Massachusetts.