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How Safe Is Our Health Care System?
Leslie Kirle, M.P.H., Senior Director of Clinical Policy and Patient Advocacy, Massachusetts Hospital Association, Burlington, MA.
Nancy Ridley, M.S., Assistant Commissioner, Health Quality Management, Massachusetts Department of Public Health, Boston, MA.
This presentation described the Massachusetts Coalition for the Prevention of Medical
Errors, a joint initiative undertaken by the Department of Public Health (DPH) and the
Massachusetts Hospital Association (MHA), along with more than 20 other professional organizations and regulatory agencies. In the 1980s, regulatory requirements in Massachusetts required hospitals to report incidents that resulted in serious injury. While presuming to provide public protection, there was actually little enforcement of the requirement.
A series of events in the mid-1990s led to the creation of the coalition and a consensus that reduction of medical errors and development of prevention initiatives must be a major priority within the Commonwealth.
- 3/95—Dana Farber incident in which a patient died due to an error in medication
- 5/95—DPH Circular letter alerting hospitals to the factors leading to the incident.
- 9/95—MHA briefing.
- 1/96—MHA Medication Project.
- 10/96—National forum on medical errors.
- 1/97—First coalition planning meeting.
- 7/98—Officially launched statewide coalition.
Short-term goals of the coalition are to identify and disseminate best practices, beginning with medication errors, and to conduct educational and training programs. In the Long-term, the coalition hopes to reduce regulatory duplication and change a "culture of fear" into a "culture of safety." The coalition is committed to improving patient safety by sharing strategies to prevent medical errors. The coalition is not an effort to publicly report on error rates or to develop comparative data on hospitals.
Members of the Medical Error Coalition include:
- Public and private agencies (Joint Commission on the Accreditation of Healthcare Organizations, Public Health, Health Care Financing Administration, Boards of Registration (physicians, pharmacists, nurses), etc).
- State professional associations (MHA, Medical Society, Nurses Association, Nurse
Executives, and Extended Care (Nursing Home) Federation).
- Clinical researchers.
- Liability insurers.
Through funding from MHA and DPH, the coalition supports participation by providers, clinicians, regulators, and researchers. Grants and other contributions have been used to develop consumer pamphlets and sponsor a leadership forum.
To date, the coalition has finalized its mission, structure, and consensus-building process. Medication best practices have been developed and circulated to the provider community, including provider educational programs. A longer term initiative has also been started to design tools for competency testing and dosage calculation, similar to ones recently instituted by the State Health Department, to reduce medication errors in nursing homes.
Other results to date include:
- Developed consumer pamphlet and a series of safety alerts.
- Conducted leadership forum with the National Patient Safety Foundation.
- Spawned coalition member initiatives.
- Generated national interest in coalition model.
The establishment of three consensus-building groups is part of the next step for the coalition.
These groups will include: Medication Group, Prevention of Restraint-Related Injuries, Regulatory Duplication and Overlap. The experience of the Medical Error Coalition provides important lessons for other States and professional groups:
- Maintain unity by emphasizing shared goal of patient safety.
- Secure support at leadership level.
- Involve clinicians throughout the process.
- Learn from others already active in the field.
- Strike a balance: quick solutions versus broad buy-in.
- Engage the media, but don't let them drive the process.
- Recognize that everyone has a seat at the table.
Massachusetts Coalition for the Prevention of Medical Errors. Mission statement. Burlington (MA): The Coalition: 1999 May.
Massachusetts Coalition for the Prevention of Medical Errors. Your role in safe medication use. Burlington (MA): The Coalition: 1999 Jun.
Massachusetts Coalition for the Prevention of Medical Errors. MHA best practice recommendation to reduce medical errors. Burlington (MA): The Coalition: 1999 Sep.
Massachusetts Coalition for the Prevention of Medical Errors. Enhancing patient safety and reducing medical errors in health care. Burlington (MA): The Coalition: 1999 Nov.
Massachusetts Coalition for the Prevention of Medical Errors. Safety first: wrong-route errors. Burlington (MA): The Coalition: 1999 Jun.