Patient Safety Beat talks with four experts from Massachusetts — Deborah Washington, Karthik Sivashanker, Matilde Castiel and Milagros Abreu — who share their thoughts on addressing structural inequities, improving outcomes and, in the end, advancing safe care for all.
Although medical harm can affect anyone, research has revealed significant disparities in safety outcomes based on race, ethnicity, age, disability, sex, gender and other characteristics. The state’s new strategic plan, the Roadmap to Health Care Safety for Massachusetts, centers the elimination of these disparities in its definition of safety, and embeds equity in the strategies and action steps for achieving the Roadmap’s goals. 

To help the patient safety community stay abreast of recent developments, we offer highlights of newly published studies, policy announcements, and other news affecting health care safety in Massachusetts.

  • Misdiagnosis results in death or permanent disability for nearly 800,000 Americans each year according to a new study. Researchers applied accepted rates of diagnostic error to estimates of disease incidence across all settings to calculate the new estimate.
  • Working with the Health Equity Compact, the Blue Cross Blue Shield of Massachusetts Foundation estimates health inequities cost $5.9 million annually in the state. A new report provides background and methodology, including how to calculate avoidable health care spending and lost labor productivity due to poor health, plus the value of lost years due to premature death across all populations.
  • The Pennsylvania Patient Safety Reporting System's annual report for 2022 shows some unexpected results. While the overall number of incidents decreased, the number of serious and high harm events increased. Pennsylvania collects more data on patient harm events than any state in the country.
  • September is Sepsis Awareness Month. Join the Betsy Lehman Center in spreading the word to Massachusetts residents on how to be “Sepsis Smart,” with materials available in English and Spanish.
Upcoming events
Aug. 22
2 - 3 p.m.
National Action Alliance webinar: Engaging Boards and Executive Leadership in Safety. The National Action Alliance to Advance Patient Safety (established by the Agency for Healthcare Research and Quality) is a public-private collaboration to improve both patient and workforce safety. This webinar is sponsored by the Centers for Medicare and Medicaid Services. Register here
Sept. 29
10 a.m. - 12:30 p.m.
Save the Date: 10th annual Communication, Apology and Resolution (CARe) Forum. This year’s CARe Forum will present case simulations and other material for live discussion in Boston, with an online option. Registration is free and will open at the end of the summer. For more information, contact Melinda Van Niel, CARe Program Director.
Oct. 19 - 20
Human Factors: A Systems Approach to Patient Safety. This live event from Medstar Health applies a human factors approach to supporting the way humans work, minimizing the opportunities for error and empowering teams to deliver high-quality care. Early registration through Sept. 1 is $795. Learn more and register

Advancing Equity through Quality and Safety Peer Network Series. This free, 20-module CME series offers training for medical professionals, executives, diversity equity and inclusion leaders, patient leads and others for integrating equity into quality and safety systems. Offered by the AMA Center for Health Equity, with the Brigham and Women’s Hospital and The Joint Commission. Learn more and register
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.