Videos of case simulations and a first-person account of a family’s experience of medical harm were the focus of this month’s CARe Forum and are now available on the Betsy Lehman Center website. CARe — Communication, Apology and Resolution — is a Massachusetts-based program that organizations can use to meet the informational and emotional needs of patients and families, as well as clinicians and staff, after an adverse or unexpected event in medical care.
The negligent homicide conviction of RaDonda Vaught, a nurse who gave the wrong medication to a patient, has renewed interest in “just culture” workplace models. Patient Safety Beat talks with Barbara Olson, M.S., R.N., CPPS, Senior Advisor with The Just Culture Company, about how to manage human error and at-risk behaviors in a complex system to improve patient safety.

“In my own work in safety, I don't want to be remembered for telling workers what they shouldn't do. I want to be remembered for saying there's a better way to do it and this is what it looks like.” — Barbara Olson

Researchers at the Betsy Lehman Center found considerable variability across health care facilities when trying to assess the frequency of patient harm after gastrointestinal (GI) endoscopies performed in outpatient hospital settings and ambulatory surgery centers in the state. An analysis of claims data showed that unplanned hospital visits by patients within 7 days of their screening colonoscopies ranged from 5.6 to 26.2 per 1000 procedures. Variation was even more pronounced for non-screening colonoscopies (4.9 to 49.5 per 1000) and esophagogastroduodenoscopies (13.2 to 112.3 per 1000). The analysis also showed that GI endoscopy patients experienced fewer unplanned hospital encounters within 7 and 30 days of their procedures at ASCs compared to hospital outpatient centers, after risk-adjustment. A limitation of the study is that claims data cannot discern reasons for the differences, which could range from sedation and procedure-characteristics to patients’ overall general health before the procedure.

Upcoming events
June 22
1 - 3 p.m.
What Patients Are Saying: Insights About Primary Care From MHQP’s Statewide Patient Experience Survey. This session will explore results from the Massachusetts Health Quality Partners' patient experience survey and how they can be used to drive measurable improvements in care. Register here
June 23
12 - 1:45 p.m.
NEJM Catalyst presents executives, clinicians and researchers from leading health care organizations sharing how they instituted change and emphasized systemic responses. Register here
July 13
12 p.m.
Advancing Equity Through Quality and Safety. Dr. Karthik Sivashanker, Vice President of Equitable Health Systems in the Center for Health Equity at the American Medical Association, shares how to design and implement interventions that support equity. Register here
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.