Mass. Hospitals Interested In Pilot Program To Identify Medical Error Cases

BOSTON (State House News Service) — A proposed pilot program for Massachusetts hospitals could be "game-changing" in identifying medical error cases and the causes behind them, the Betsy Lehman Center's executive director said Monday, and several hospitals have expressed interest in taking part. But the project's on hold while the center tries to secure funding for it from state lawmakers.

The Lehman Center, an independent state agency focused on reducing errors in medical care, is diving into a multi-year "roadmap" released in April with more than 30 action items aimed at bolstering health care safety. Its initial steps for this year hinge on $3.5 million in one-time spending the agency hopes lawmakers will bake into the fiscal 2024 budget.

Executive Director Barbara Fain said the heaviest lift among the short-term goals is the pilot of "automated safety event surveillance" at Massachusetts hospitals. The practice analyzes electronic medical records to learn about the driving factors behind medical errors, potentially turning up "about 25 times the4 number of safety events" that hospitals are currently detecting.

That means it takes "a certain amount of courage" for a hospital to sign on, she said, but the long-term benefits can include public recognition of a hospital's work to cut down on errors, and recognition by liability carriers of positive progress.

The center hopes to have six to eight Bay State hospitals participate, and several hospitals -- both large and small -- have expressed interest, Fain said Monday after a briefing at the State House.

She called the automated surveillance "the wave of the future."

"There are a small handful, less than a handful, of national vendors who have these systems, and so what's involved is contracting with them to actually provide the software, the technology, that runs in the background of the electronic health record and picks out these harm events. They provide analytics, as well, so it's not just raw data. One of them actually has a remote team of physicians and nurses actually sitting there, looking at the alerts that these systems are providing, and validating them in the electronic health record so it's not providing a lot of false alarms," Fain said.

In addition to data analytics, the program would support technical assistance and coaching to help hospitals identify trends and driving factors behind the errors, which she said can lead to declines in preventable cases of patient harm within just months.

"To me, that's the exciting part," she told the News Service. "It's not just counting up how many errors can we find -- we already know we'd find a lot ... The big question is, if we find them, will we see that reduction in harm? Because that's really the goal here."

The House's budget deliberations in April came shortly before the roadmap was released, she said, and the center is turning now to the Senate and a budget amendment filed by Sen. John Cronin (No. 507) to set aside $3.5 million in a separate line item for the pilot projects. The automated record surveillance project would account for around $2.7 million of that appropriation.

"The Betsy Lehman Center's entire budget is $2.5 million. We're little. We punch above our weight, but we're a very small group," Fain said.

Other 2023 projects that hinge on the budget funding request include development of a statewide health care safety curriculum and creation of a pilot program aimed at procedures in smaller outpatient medical practices.

A pre-pandemic report from 2019 showed "tens of thousands of preventable harm events in a single year" in Massachusetts health care settings, the center said, and a phone survey found that one in five Bay Staters said they experienced medical errors in the preceding five years.

The roadmap, compiled with the Mass. Healthcare Safety and Quality Consortium, takes a long-term approach phased over five to 10 years. The plan is divided into five categories addressing leadership and workplace culture, operations and engagement with staff and patients, patient and family supports, workforce wellbeing, and data measurement and transparency.

On the operational side of the health care system, the plan looks to build a "safety culture" at provider organizations with "a mindset of zero-tolerance for defects that can result in physical or emotional harm to patients, or families or staff," Fain said.

"Human errors are always going to be a reality, not just in health care, but anywhere. I mean, we all make mistakes. We can't eliminate mistakes. But in a safety culture, leaders are focusing on addressing these underlying issues that are contributing to safety breakdowns, and they're also supporting their workforce when systems break down and errors occur," she said.

The center was named after Betsy Lehman, a Globe health reporter who died in 1994 following a medical care error at a Massachusetts hospital.

Sen. Cindy Friedman recounted Lehman's story at the briefing, and said that "after 30 years, we are still seeing a number of events that are caused by medical error, and so we know that this is something that we need to continue to be vigilant about."

Rep. John Lawn, who with Friedman co-chairs the Health Care Financing Committee, said there is "an urgent need to prioritize safety and prevent preventable patient harm."

The Legislature "can and will help create favorable conditions for improvement, but real change will also take leadership from within the provider community," Lawn said.

The Watertown Democrat gave an example of a proactive health care worker doing her part to keep patients safe: his daughter, a nurse, earned a "Good Catch Award" at her hospital a couple months ago after she noticed a pharmacy error in a fentanyl dosage and stopped it from reaching the patient.

That's part of "the provider community working together," Lawn said.

Written By Sam Doran/SHNS

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