The Betsy Lehman Center plays a strategic coordinating role among state agencies and other organizations dedicated to making health care safer in the Commonwealth. The Center has embarked on a robust program of research, data analysis, and communication that engages Massachusetts health care agencies, providers and consumers toward a goal of zero harm.
As part of this effort, the Center created a web-based Patient Safety Navigator to help Massachusetts health care providers effectively respond to adverse events that occur in the course of clinical care by providing usable tools to understand how to communicate about, analyze the causes of, and report these incidents.
We created the Navigator through extensive research into both state and federal reporting obligations; ongoing vetting and dialogue with other state agencies including the Department of Public Health, the Quality Patient Safety Division of the Board of Registration in Medicine, and the Department of Mental health, among others; iterative web development and design; and user testing and feedback sessions with health care facility staff.
In 2015, the Betsy Lehman Center set out to “map” providers' reporting obligations for adverse clinical events to better understand what information is being collected, particularly by the state. What we found is a complex regulatory landscape that is critical to monitoring patient safety—but also at times complicated to understand. Working with multiple state agencies, we researched, mapped, and designed a system to guide health care providers on how to report key patient safety events. Concurrently, we developed complementary modules, “Communicate” and “Analyze,” to help providers not only report, but also disclose and learn from, adverse events when they occur.