Massachusetts Hospitals Take on Preventable Errors

BURLINGTON, Mass. — The Mass. Hospital Association (MHA) recently announced that all Massachusetts hospitals will adopt a uniform policy not to charge patients or insurers for certain serious adverse events as defined by the National Quality Forum (NQF), including wrong-site surgeries and serious medication errors. In doing so, Massachusetts becomes only the second state in the nation to take this voluntary action.

“This represents a major step forward and builds on several groundbreaking transparency and quality initiatives that have put us ahead of the curve nationally,” said Lynn Nicholas, FACHE, President and CEO of the (MHA). “This policy sends a strong message to patients that their hospital is committed to doing everything possible to eliminate these types of events.”

“The leadership demonstrated in this action signals strongly the energy and resolve our state’s health care executives are bringing to advancing the quality and safety of care in Massachusetts. It also establishes a model of accountability for other states and provider groups around the nation to learn from and emulate,” said James Conway, senior vice president, Institute for Healthcare Improvement.

The policy, to be put into effect early this year, will codify long-standing safety practices and fortify hospitals’ commitment to preventing adverse medical events. The policy will apply to any of the defined events and any subsequent care needed to manage the event. The hospital community will work collaboratively with an advisory group comprised of hospital members from both clinical and financial departments, the physician community, health insurance companies, and patient-consumer representatives to implement the plan.

“This represents an important step forward for the entire health care community,” said Dr. Marylou Buyse, a practicing primary care physician and president of the Mass. Assoc. of Health Plans. “We applaud this effort and look forward to working with hospitals to put it into place.”

The policy will cover nine rare but serious adverse events, and is based on nationally accepted definitions. The list includes:

• Surgery on wrong body part;
• Air embolism-associated injury;
• Surgery on wrong patient;
• Medication error injury;
• Wrong surgical procedure;
• Artificial insemination/wrong donor;
• Retention of foreign object;
• Infant discharged to wrong family;
• Incompatible blood-associated injury.

Under current practice, in the extremely rare case that a serious adverse event does occur, Massachusetts hospitals disclose the incident and apologize to the patient. Additionally, hospitals report the incident to separate programs at the Department of Public Health and the Board of Registration in Medicine.