Becker's Clinical Quality & Infection Control

24 QUALITY IMPROVEMENT & MEASUREMENT 5 ways Massachusetts hopes to reduce medical errors statewide By Ashleigh Hollowell M edical errors kill up to 9,000 patients per year. e death of Betsy Lehman, a cancer patient — and former columnist for e Boston Globe — as a result of a medical error in Boston nearly 30 years ago, has now prompted Massachusetts to embark on revamped efforts to address medical errors in health facilities. e Betsy Lehman Center for Patient Safety, a state agency that aims to improve patient safety and outcomes, published a comprehensive Roadmap to Health Care Safety for Massachusetts, outlining goals and strategies to achieve them. "Massachusetts has a long history of breakthroughs on intractable health system challenges," the plan's executive summary reads. "During this time of recovery from the disruptions of the pandemic, we are well-positioned to chart a new course through a public-private partnership that leverages proven strategies to advance safety, health equity, workforce well-being, operational efficiencies that improve care and lower costs and patient experience." e roadmap's five goals to achieving better patient safety standards are outlined as: 1. Healthcare leaders must play a central role in establishing and sustaining cultures of safety and improvement at their respective organizations. 2. Healthcare organizations and facilities must have standards and clear processes to equip their employees with tools they need to identify safety issues and execute appropriate responses accordingly. 3. Communication with patients and families should be clear, timely and provide the information necessary for them to avoid medical errors and harm in their own care at home. 4. Healthcare organizations are safer for patients when they are taking care of their employees and removing barriers and causes of undue stress and unnecessary processes that are ineffective or contribute to safety risks in any way. 5. State healthcare data is up-to-date, transparent, usable and timely for clinicians, organizations, policymakers and other stakeholders to understand and utilize for improved safety practices. e agency underscores that these goals must be executed with clear strategies and the "collective statewide effort among provider organizations, patients, payers, policymakers, regulators and others." n Adverse events rose 19% in 2022, Joint Commission finds By Ashleigh Hollowell N ew data from The Joint Commission found that of all reported sentinel events in 2022, 44 percent resulted in severe temporary harm and 20 percent resulted in a patient death. The Joint Commission defines a sentinel event as a patient safety event that reaches a patient and results in death, permanent harm or severe harm. There were 1,441 reports of sentinel events in 2022, up by 19 percent from 2021, according to the report. The increase is above pre-pandemic levels, according to the April 4 news release. The top ten categories of sentinel events were: 1. Falls — 42 percent 2. Delay in treatment — 6 percent 3. Foreign object retention — 6 percent 4. Undergoing the incorrect surgery — 6 percent 5. Suicide — 5 percent 6. Assault/rape/sexual assault/homicide — 4 percent 7. Fire/burns — 3 percent 8. Perinatal event — 2 percent 9. Self-harm — 2 percent 10. Medication management — 2 percent Sentinel event data reporting to The Joint Commission is a policy that was established in 1996 to improve patient safety. Hospitals, healthcare professionals, and even patients and families can report instances of these occurrences to the Commission, and that data is then aggregated and analyzed on an annual basis. The Joint Commission's report found that the most common causes of these adverse events that result in harmful outcomes are failures in communications, failures in teamwork and failures in consistently following policies. "For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies," Haytham Kaafarani, MD, the chief patient safety officer and medical director for The Joint Commission, said in a statement. "Our goal is to help prevent these types of adverse events from occurring again." However, because reporting sentinel events is a voluntary process, The Joint Commission notes that drawing any conclusions about trends over time from the data should be avoided. n

• Cover