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Summer 2016

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Up Front

Introducing the Navigator: A new tool to help providers respond to patient safety events

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The Betsy Lehman Center launches a new online tool that makes it easier for hospitals and other health care facilities to file patient safety reports required by state law, as well as communicate about and learn from patient harm events.

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FIVE QUESTIONS WITH ...

Robert Truog, MD

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The well-known Harvard Medical School authority on bioethics and medical communication talks about the challenges of apology and resolution after a medical error.


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SAFETY NEWS

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Nearly 1,500 adverse events reported to the state last year

The 2015 statistics on Serious Reportable Events, just released by the Department of Public Health, show room for improvement, some notable achievements, and the need for more robust reporting.


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Explainer: What do the adverse event report data tell us?

Don't draw too many conclusions about quality of care from adverse event data. There are valuable lessons to be learned from an annual look at these numbers, but SREs offer just one small — and incomplete — snapshot of the state of patient safety in Massachusetts.


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Atrius Health is changing the way ambulatory care providers resolve patient harm incidents

The state's largest ambulatory care group is one of the first primary care networks to adopt communication, apology and resolution practices to respond to cases of medical error. Dr. Beverly Loudin at Atrius Health talks about how things are going.


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SAFETY IN A SINGLE GRAPHIC

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In a 2014 survey by the Harvard School of Public Health, 23 percent of Massachusetts adults said they, or someone close to them, experienced a medical error in the prior five years. Above were the health consequences they reported.

Click to view full graphic

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UPCOMING EVENTS

9th Annual NPSF Lucian Leape Institute Forum & Keynote Dinner

When:Thursday, September 15

Where: Westin Waterfront Hotel, Boston, MA

Details and registration

 

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Let us know about your upcoming event.

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JUST ONE THING

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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.


Electronic medical records can be clunky and frustrating, so work-arounds are common. But copying existing information from one field of a patient's record and pasting it into another is risky. Shy of re-configuring your EMR system, what can you do to minimize the chances of triggering a patient harm when using this shortcut?

 

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FROM THE DIRECTOR

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We're proud to announce the launch of our Patient Safety Navigator, a first-in-class online tool that helps decode state and federal reporting systems that collect information on patient safety events. We built the Navigator to support safety and quality improvement by all health care providers, while also contributing to a stronger collective understanding of persistent and emerging patient safety risks. It would be impossible to overstate the important contributions made by so many: from hospital and ambulatory surgery center staff who were our early focus groups and testers; to staff at state agencies who responded to our endless questions about their reporting systems to ensure the Navigator's information is on the mark; to the patient safety experts who helped us repurpose their valuable work on analyzing adverse events and communicating about them. We are now ready to throw open the Navigator's doors to all, and hope you will send us your feedback and suggestions for making this resource an even more robust catalyst for patient safety progress.

If you're not already a subscriber, be sure to sign up to get each new edition.
And, if you have a comment or story idea for a future edition, we'd love to hear it!

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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.

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