Massachusetts stats show better safety reporting can make problem seem worse

Quality and safety improvement begins with accurate measurement of the problem, including recording every incident regardless of whether a patient was seriously harmed or not. However, recent data from Massachusetts shows that better measurement can create a drastic increase in the rate of adverse events — in this case an attention grabbing jump of 70 percent in one year.

According to the Boston Globe, Massachusetts acute-care hospitals reported 753 serious medical errors and other patient injuries that qualify as reportable events last year. In addition, reportable events at psychiatric, rehabilitative and other types of hospitals rose 60 percent.

Before October 2012, Massachusetts hospitals only had to notify the state when incidents left a patient with a “serious disability.” However, following national guidelines, the state expanded the definition to incidents where there is any serious injury and added four new reporting categories, including patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results.

While a 70 percent increase in adverse events is startling, Madeleine Biondolillo, M.D., the associate commissioner of the Massachusetts Department of Public Health, cautioned in the Boston Globe article that not too much should be read into the numbers until the 2014 data is released because of the big change in what qualified as a reportable event that occurred in 2012.

The movement toward better error reporting has a hallmark of patient safety and quality work for over a decade and is especially associated with the 2001 publication of the “Patient Safety and the ‘Just Culture:’ A Primer for Health Care Executives” report by David Marx, J.D., which holds that for systems to improve, every error and near-miss needs to be reported. In turn, for this to happen, a “just culture” needs to exist where all healthcare providers acknowledge that mistakes will occur and it is more important to work on preventing future mistakes of the same sort than to punish a specific individual or healthcare system that made the mistake.

However, as the Massachusetts example shows, the potential of a giant jump in adverse event numbers due to better reporting is something that may be hard to explain to the public and can make providers balk at embracing better adverse event reporting.