The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center

 
The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center
The Financial and Human Cost of Medical Error
           ... and How Massachusetts Can Lead the Way
                                     on Patient Safety

                                            JUNE 2019
The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center
EXECUTIVE DIRECTOR
                     Barbara Fain

                  BOARD MEMBERS
                    Maura Healey
                  Attorney General

               Marylou Sudders
           Secretary of Health and
                 Human Services

                Edward Palleschi
      Undersecretary of Consumer
   Affairs and Business Regulation

                    Ray Campbell
Executive Director of the Center for
   Health Information and Analysis
The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center
PREFACE AND ACKNOWLEDGEMENTS
This report, and the two research studies upon which it is based, aims to fill information gaps about the incidence and key risks to patient safety in Massachusetts,
increase our understanding of how medical error impacts Massachusetts patients and families and, most importantly, propose a new, concerted effort to reduce
medical error in all health care settings in the Commonwealth.

Many individuals and organizations made meaningful contributions to this work, for which we are extremely grateful:

• Betsy Lehman Center Research Advisory Committee, whose members                    • SSRS, which fielded the survey, including David Dutwin, PhD; Susan Sherr,
    offered insightful feedback on our methodologies and analyses including:            PhD; Erin Czyzewicz, MEd, MS; and A.J. Jennings
    David Auerbach, PhD, Health Policy Commission; Laura Burke, MD,                 •   Center for Health Information and Analysis (CHIA), especially Ray
    Harvard Global Health Institute; Ray Campbell, JD, MPA, Center for                  Campbell, JD, MPA; Lori Cavanaugh, MPH; Amina Khan, PhD; Mark
    Health Information and Analysis; Katherine Fillo, PhD, RN, Massachusetts            Paskowsky, MPP; Deb Schiel, MHA; Huong Trieu, PhD; and Zi Zhang, MD,
    Department of Public Health; Jose Figueroa, MD, MPH, Harvard Global                 MPH for the many ways they supported both research studies
    Health Institute; Paula Griswold, Massachusetts Coalition for the Prevention
    of Medical Errors; Carol Keohane, MS, RN, CRICO; James Lee, Tufts               • Other state agencies including the Attorney General’s Office; Department of
    University School of Medicine; Timothy O’Neill, Joint Committee on Health           Public Health; Health Policy Commission; MassHealth; and the Quality and
    Care Financing; Barbra Rabson, MPH, Massachusetts Health Quality                    Patient Safety Division, Board of Registration in Medicine, which provided
    Partners; Mark Schlesinger, PhD, Yale University School of Public Health;           valuable feedback
    Eric Schneider, MD, MSc, Commonwealth Fund; Joel Weissman, PhD,                 •   Massachusetts health organizations, which offered helpful engagement
    Center for Surgery and Public Health, Brigham & Women’s Hospital; and               and support, including: Blue Cross Blue Shield of Massachusetts; Coverys;
    Zi Zhang, MD, MPH, Center for Health Information and Analysis                       CRICO; Institute for Healthcare Improvement; Massachusetts Alliance for
•   Our survey advisory group, which met regularly to assist in the survey’s            Communication and Resolution following Medical Injury; Massachusetts
    design and analysis, including: Sigall K. Bell, MD, Beth Israel Deaconess           Association of Ambulatory Surgery Centers; Massachusetts Association of
    Medical Center; Rear Admiral Jeffrey Brady, MD, MPH, Agency for                     Health Plans; Massachusetts Coalition for the Prevention of Medical Errors;
    Healthcare Research and Quality; Caren Ginsberg, PhD, Agency for                    Massachusetts Health and Hospital Association; Massachusetts Medical
    Healthcare Research and Quality; Patricia McGaffigan, RN, MS, Institute for         Society; Massachusetts Senior Care Association; and Steward Health Care
    Healthcare Improvement; Eric Schneider, MD, MSc, Commonwealth Fund;             •   Additional experts who generously reviewed our methodologies, analyses,
    Mark Schlesinger, PhD, Yale School of Public Health; Eric Thomas, MD,               and report or contributed other knowledge at critical steps along the way,
    MPH, University of Texas Health Science Center; Saul Weingart, MD, MPP,             including: Evan Benjamin, MD, MS, Ariadne Labs; Donald Berwick, MD,
    PhD, Tufts Medical Center; Joel Weissman, PhD, Center for Surgery and               MPP, Institute for Healthcare Improvement; Tejal Gandhi, MD, MPH, Institute
    Public Health, Brigham & Women’s Hospital                                           for Healthcare Improvement; Erin Grace, Agency for Healthcare Research
•   Our survey coding team at Yale University School of Public Health, led by           and Quality; Ashish Jha, MD, MPH, Harvard University; Michele Mello, JD,
    Mark Schlesinger, PhD, that analyzed the survey narratives, with special            PhD, Stanford University; Jennifer Moore, PhD, University of New South
    thanks to Isha Dhingra, MD and Vinita Parkash, MBBS, MPH                            Wales, Sydney; and Mark Reynolds, CRICO

We also want to extend special recognition to our survey respondents, in particular the 253 Massachusetts residents who were willing to speak with our research
team at length and on multiple occasions about their recent experiences with medical error. Several of these individuals told us they were thankful for the survey,
which allowed them an opportunity to reflect and communicate about a difficult period in their lives. They were especially motivated to share their thoughts and
feelings in the hopes that it would spark change and prevent future harm to other patients. We, in turn, appreciate everyone who took the time to talk with the
survey team. The experiences they shared—which ranged from mildly upsetting to life-altering—will continue to inform and inspire our work. All quotations that
appear in this report are from medical error survey respondents, used with permission.

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                           ©2019 Betsy Lehman Center for Patient Safety   l   i
The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center
TABLE OF CONTENTS

•   About this report ........................................................................................................................1
•   Medical error was first recognized as public health challenge over 25 years ago ...............2
•   Progress has been made over the past 25 years, but the health care system
    remains prone to error and there are no easy fixes ................................................................3
•   What we know—and don’t know—about medical error in Massachusetts, and
    why it matters .............................................................................................................................4
•   Two new studies look beyond existing reporting systems to fill important gaps in
    what we know about the costs of medical error ...................................................................5-6
•   Key findings ...............................................................................................................................7
•   FINDING: Medical errors are frequent, harmful, and costly ...................................................8
•   Our incidence and cost calculations are conservative estimates ..........................................9
•   FINDING: Medical errors happen in all health care settings throughout
    Massachusetts and can happen to anyone ...........................................................................10
•   FINDING: Medical errors are associated with long-lasting physical and
    emotional impacts ....................................................................................................................11
•   FINDING: Medical errors are associated with long-lasting loss of trust and
    avoidance of health care .........................................................................................................12
•   FINDING: Patients and families rarely receive an apology or offer of support
    following a medical error .........................................................................................................13
•   FINDING: Most people are dissatisfied with the communication they receive
    from providers after an error ...................................................................................................14
•   FINDING: For people who receive it, open communication is associated with
    lower levels of adverse emotional health impacts and health care avoidance ...................15
•   Patients and families are astute observers of what happened and why things
    went wrong .........................................................................................................................16-17
•   How Massachusetts can lead the way on patient safety .................................................18-19
•   Conclusion ...............................................................................................................................20

•   References ..........................................................................................................................21-23
•   Appendix A ..........................................................................................................................24-30
•   Appendix B ..........................................................................................................................31-36

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                                       ©2019 Betsy Lehman Center for Patient Safety   l   ii
About this report

There has been considerable progress on improving      preventable patient harm. It then measured the cost      An important and promising finding is that in
the safety of health care for patients over the past   of health care services in the aftermath of the error.   instances where providers communicated more
two decades. Much of this work has been done by        The second study began with a random-sample              openly, patients report less emotional harm and
hospitals in Massachusetts and across the country.     survey of 5,000 Massachusetts households that            health care avoidance.
Yet, medical error continues to cause hundreds         identified almost 1,000 people who reported having       The challenges are great, but so are the
of thousands of deaths and injuries each year in       experienced a medical error in their own care or         opportunities for improvement—particularly
the United States.1,2 Preventable safety events        in the care of a household or close family member        in Massachusetts. In addition to presenting
now occur in 115 of every 1,000 hospitalizations,3     within the previous five years. In a follow-up survey,   the research findings, this report proposes
costing payers an average of $8,000 per                253 of these individuals shared detailed information     a coordinated response through which the
admission.4,5 As more care is delivered outside of     about the impacts of those errors, and about the         Commonwealth’s providers, policymakers, and
hospitals, risks to patient safety are an emerging     communication or support they received from              public can begin to accelerate safety and quality
concern in physician practices, dental offices,        health care providers in the aftermath of the errors.    improvement, and once again lead the nation on
surgery centers, pharmacies, dialysis centers,         In short, Massachusetts providers in every setting       an urgent health care challenge.
patients’ homes, nursing homes—anywhere                where health care is delivered face the same
patients receive care. Medication errors are           patient safety challenges that persist throughout
among the most common errors in outpatient and         the nation.
inpatient settings.6 And one in 20 U.S. adults who
seek outpatient care will experience a diagnostic      Our research uncovered almost 62,000 medical
error each year, with about half of the errors         errors, which were responsible for over $617
considered potentially harmful.7                       million in excess health care insurance claims in
                                                       a single year—just exceeding one percent of the             The Betsy Lehman Center is a non-regulatory
Massachusetts gets high marks for the overall          state’s Total Health Care Expenditures for 2017.            state agency that catalyzes the efforts of
performance of its health system on metrics such       Because some of the most common types of errors             providers, patients and policymakers working
as access to care, children’s vaccination rates, and   (for example, medication and diagnostic errors)             together to advance the safety and quality
30-day hospital mortality.8 Data specific to patient   cannot be reliably identified using health insurance        of health care in all settings. Established by
safety is more limited. In the only national ranking                                                               Chapter 224 of the Acts of 2012, the Center’s
                                                       claims data, these numbers underestimate both               mandate includes:
of safety, Massachusetts hospitals are highly          total incidence and cost.
rated9 though similar rankings are not available for                                                               •   Facilitating agency and provider collaboration
outpatient and long-term care.                         From our surveys, we learned that many of the                   on system-wide patient safety improvement
                                                       people who report recent experience with medical                initiatives
To add to our knowledge about the impact of            error are suffering long-lasting behavioral, physical,
preventable medical error in Massachusetts, the                                                                    •   Administering a program of research
                                                       emotional, and financial harms. Individuals report              and data analysis
Betsy Lehman Center undertook two studies.             that they have lost trust in the health system and
The first study analyzed one year’s worth of health    some avoid not only the clinicians and facilities           •   Developing mechanisms to include patients
                                                                                                                       and families in safety improvement efforts
insurance claims data to count the number of           responsible for their injuries, but health care
medical errors in a variety of health care settings    entirely. Moreover, most respondents expressed              •   Reporting on the Commonwealth’s
                                                                                                                       safety improvement progress
using almost 100 diagnostic codes that previous        dissatisfaction with how their health care providers
studies have shown to be associated with               communicated with them after the errors.

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                          ©2019 Betsy Lehman Center for Patient Safety   l   1
Medical error was first recognized as public health challenge over 25 years ago

Betsy Lehman was a nationally recognized Boston        At the national level, the Institute of Medicine’s
Globe health columnist and mother of two young         1999 report, To Err Is Human: Building a Safer
girls when she died of a massive overdose of           Health System,1 drawing from the groundbreaking
chemotherapy while being treated for breast            work of Lucian Leape10 and others,11 established
cancer at the Dana-Farber Cancer Institute on          medical error as a leading cause of death. The
December 3, 1994. At the time, health care             report was a call to action for the health care system
providers were not in the practice of reporting        to recognize and respond to systemic contributors
serious harm events to the state’s regulatory          to preventable medical harm. It also laid out a
agencies. Nor did they typically disclose errors to    comprehensive path forward that could be driven
patients and families.                                 through collaborative, multi-stakeholder efforts.
In Betsy Lehman’s case, about two months after         In Massachusetts, a group of regulators and
her death, Dana Farber staff discovered the            health care providers joined together as the
medication error and informed her family. Her          Massachusetts Coalition for the Prevention of
colleagues at the Globe made the decision to           Medical Errors to strategize over how to introduce       CLICK HERE TO VIEW BETSY LEHMAN’S STORY.
provide extensive, sustained coverage not only of      a more collaborative and less punitive approach
the error leading to her death but of the broader      focused on learning from and preventing the
risks to patient safety. The Department of Public      recurrence of medical harm. Such an approach
Health was alerted to the overdose by the Globe’s      would emphasize identifying root causes of
coverage and launched an investigation.                adverse events, developing corrective action
                                                       plans, and disseminating this information across
In Massachusetts and nationally, Betsy Lehman’s
                                                       providers. The Coalition and Betsy Lehman’s
death catalyzed a movement to recognize that
                                                       family also advocated for the legislature to create
patient harm is not always caused by an indivudal
                                                       a non-regulatory state agency in her name to
clinician’s negligence. Rather, preventable
                                                       coordinate, support, and report on the patient
medical harm can be viewed as a consequence of
                                                       safety improvement efforts of the state’s provider
institutional systems and culture that had not kept
                                                       organizations and health care agencies, and to
pace with the complexities of modern health care.
                                                       engage the public.
The challenge and the opportunity, then, would be
to apply interventions developed by other complex,     Some of these patient safety pioneers believed that
high-risk industries that had succeeded in achieving   by adapting and implementing the high reliability
high levels of safety and reliability.                 and safety principles and practices of other
                                                       industries such as aviation and nuclear power,12,13
                                                       the health care system could eliminate most
                                                       preventable patient harm.

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                     ©2019 Betsy Lehman Center for Patient Safety   l   2
Progress has been made over the past 25 years, but the health care system remains
    prone to error and there are no easy fixes
Investments in safety improvement in                   have successfully targeted safety risks such           • Factual foundation. Current systems for
Massachusetts and nationally are making a              as overdiagnosis of urinary tract infections,            detecting, reporting, and analyzing adverse
difference, particularly in hospitals. Earlier this    communicating critical test results, and medication      events and safety risks do not always yield
year, the Agency for Healthcare Research and           errors.                                                  enough meaningful data to sufficiently inform
Quality and the Centers for Medicare & Medicaid        However, many forces conspire against consistent         leadership of health care organizations or to
Services (CMS) released data showing that nine         and widespread implementation of safety plans            guide improvement at the system level.19,23,26
types of hospital-acquired conditions (HACs)           and best practices, including:                         • Misaligned incentives. In many cases, providers
declined by nearly one million instances from                                                                   are still paid not only for health care services
2014-2017, preventing over 20,000 hospital
                                                       • Complexity. The sheer complexity and pace
                                                         of modern medicine generate new and                    that result in preventable harm, but for
deaths and saving $7.7 billion nationally.14 This                                                               the additional services necessitated by the
                                                         evolving safety risks that demand never-
set of HACs, which includes adverse drug events                                                                 harm.26 Moreover, the return on investment
                                                         ending, continuous cycles of improvement.
and healthcare-associated infections, had been                                                                  for implementing safety improvements at
                                                         The unintended safety consequences of
targeted by CMS through a pay-for-performance                                                                   the provider level may seem too unreliable to
                                                         electronic medical records19 are but one
program that reduces Medicare reimbursements                                                                    executive leadership and their governing bodies.
                                                         example. Sometimes the underlying risks are
to the lowest performing hospitals, as well as
                                                         not within the direct control of providers—for
offerings of collaborative learning opportunities
                                                         instance, unclear labeling of drugs or devices by
and other resources aimed at helping hospitals
                                                         manufacturers.20                                          PROGRESS OVER THE LAST 25 YEARS
improve.
                                                       • Culture. Providers and patients alike have prized
Other strategies that either are improving or                                                                      1. The systems and cultural factors that
                                                         individual skill, autonomy and responsibility over
have the potential to improve patient safety                                                                          contribute to preventable medical harm
                                                         the teamwork and standardization needed to                   events are well understood, at least by
are documented in a recent special issue of
                                                         ensure safety in today’s heath care system.21,22             patient safety and quality professionals.
Health Affairs. These include best practices and
                                                         And some medical practices and organizations
innovations for effective communication within                                                                     2. An extensive array of evidence-based
                                                         lack safety cultures in which every staff member
care teams and between providers15 and patients16,                                                                    best practices for reducing the risk of
                                                         feels responsible and empowered to speak up                  human error and preventing patient harm
leveraging electronic health records to enable early
                                                         about risks and adverse events without fear of               when errors do occur are now available.
detection and response to errors,17 and modifying
                                                         reprisal.19,23
the built environment to prevent patient harm.18                                                                   3. A number of transparency initiatives
                                                       • Competing priorities. Health care leaders are                and financial incentives, mainly at the
In Massachusetts, a variety of collaborative safety      dealing with many competing pressures.24                     national level, now promote safety and
and quality improvement initiatives are underway,        Making safety a top priority means taking on the             quality improvement.
for example a Health Improvement Innovation              difficult task of culture change.25 Other barriers
Network led by the Massachusetts Health and              may include a sense that ambitious safety goals
Hospital Association and a Perinatal and Neonatal        are unattainable, or that one’s own organization
Quality Improvement Network administered by              is already as safe as it can be.
the March of Dimes. Past learning collaboratives

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                       ©2019 Betsy Lehman Center for Patient Safety   l   3
What we know—and don’t know—about medical error in Massachusetts,
    and why it matters
The systems Massachusetts uses to track instances       to fear that they or others will be punished for                 • How many preventable patient harm events are
of medical error are overlapping, fragmented, and       safety lapses that are reported.                                    happening statewide?
incomplete. The resulting patchwork quilt of data is                                                                     • What are the most common and most costly
                                                        To illustrate, Massachusetts mandates that
not always up to the task of informing policymaker                                                                          types of error?
                                                        hospitals and ambulatory surgery centers report
and agency decisions about safety priorities
                                                        medication errors resulting in serious injury or                 • What are the key contributors or risk factors for
at the state level. Nor does it help health care
                                                        death. In 2017, facilities reported a combined                      these errors?
providers learn from the risks identified at peer
                                                        total of 52 such errors.28 Yet, in a recent study that           • Which providers are performing better or worse
organizations to identify their own vulnerabilities
                                                        followed patients through 277 surgeries at a single                 than their peers on safety?
and take steps to prevent patient harm. Sparse
                                                        Massachusetts hospital, researchers observed that
information also contributes to low awareness
                                                        1 in every 20 medications administered involved                  • Which safety risks have been successfully
among all parties—including the public—and a                                                                                reduced and how?
                                                        an error and/or harm event. Of over 150 errors
tendency to underestimate the risks and the need                                                                         This is not to suggest that patient safety will be
                                                        found to be preventable, nearly 90 percent either
for investment in solutions.21                                                                                           achieved by more metrics and reporting alone.
                                                        caused or could have caused serious or even life-
For the most part, state and federal reporting          threatening consequences.29 Studies like this show               Indeed, sound arguments are being made
mandates apply to narrowly-drawn categories of          that if you look, you will find far more errors than             for policies that would reduce reporting and
providers (mostly hospitals, nursing homes and          providers detect and report.                                     measurement to just the right level to support
ambulatory surgery centers) and are designed to                                                                          improvement.30 To do this will require new ways of
                                                        Barriers to data-sharing among the various
capture a subset of adverse events that result in                                                                        thinking about how best to gather and use safety
                                                        custodians of the data also reduce the value of
serious injuries or death. For instance, if a dentist                                                                    data in both centralized (at the state level) and
                                                        information that the state currently receives. Data
extracts the wrong tooth or a pediatrician gives                                                                         decentralized (at the provider organization level)
                                                        silos effectively prevent anyone from gaining a
a child the wrong vaccination, the data is not                                                                           ways, and how to leverage data to maximize shared
                                                        complete picture of the existing medical error
captured. In the case of hospitals and nursing                                                                           learning across provider organizations and to hold
                                                        landscape. Because we all touch different parts of
homes, most errors that cause less serious harm                                                                          those organizations and their leaders accountable
                                                        the elephant, no one is positioned to answer such
are not required to be reported, even though                                                                             for quality and safety.
                                                        obvious questions as:
critical information could be gleaned from these
“near miss” or lower injury events.
                                                        WHICH ERRORS ARE REPORTABLE UNDER CURRENT LAW?
Underreporting of errors is widespread.27 But
while some noncompliance with reporting may be           WHEN A PATIENT ...                                         MUST THE PROVIDER REPORT IT TO A STATE AGENCY?
intentional, much underreporting is attributable         Is seriously harmed by a medication overdose in a hospital or nursing home                                            YES
to problems with a provider organization’s internal      Has the wrong eye anesthetized during cataract surgery at an ambulatory surgery center                                YES
systems for identifying and tracking adverse events      Attempts self-harm in the psychiatric unit of a hospital                                                              YES
in the first place. Weaknesses include low staff         Has cancer, but freestanding lab does not transmit screening test results to ordering physician or patient            NO
awareness, a difficult or frustrating user interface,
                                                         Has wrong tooth removed in a dentist’s office                                                                         NO
clinician and staff perceptions that reporting is
a waste of time because no one will take action          Visits the pediatrician for a flu shot and is given a vaccination intended for another child                          NO
anyway, or a culture that leads clinicians and staff    Visit the Betsy Lehman Center’s Patient Safety Navigator to learn more about patient safety reporting requirements.

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                   ©2019 Betsy Lehman Center for Patient Safety   l     4
Two new studies look beyond existing reporting systems to fill important gaps in
    what we know about the costs of medical error
Although our formal systems for collecting data                        I. THE INCIDENCE AND FINANCIAL COSTS OF MEDICAL ERROR
about patient safety in Massachusetts may be                           • Question—How many preventable medical harm events occur in one year, what are the most common
fragmented, it is possible to supplement what                            and costly types of errors, and how many dollars are spent on excess health insurance claims resulting
we know. The Betsy Lehman Center recently                                from these errors?
undertook two studies that are the first to
rigorously measure:                                                    • Approach—We applied an established methodology31 used to estimate the national cost of medical
                                                                         error using the Massachusetts All-Payer Claims Database (APCD) (which includes both commercial
1. The annual incidence, types, and system                               health insurance and Medicaid claims) and Medicare claims data encompassing most reimbursable
   costs of medical errors throughout the                                procedures or treatments. Under this approach, we identified patients for whom insurance claims had
   Commonwealth                                                          been submitted using any of 98 diagnostic codes known to be associated with preventable harm events,
2. The physical, emotional, behavioral, and                              calculated the probability that these claims were related to preventable error, and estimated the
   financial impacts of preventable medical harm                         additional health care costs resulting from those events. We used APCD and Medicare claims data for
   on Massachusetts residents                                            2013 because of a subsequent change in the diagnostic coding system.32 For preventable harm events
                                                                         that cannot be found in health insurance claims data, we partially supplemented our estimates using
                                                                         data derived from peer-reviewed literature and incident reporting systems [see Appendix A for detailed
                                                                         explanation of the methodology].

EXAMPLE:    ESTIMATING THE ANNUAL COST OF FOREIGN OBJECTS LEFT IN THE BODY AFTER SURGERY

 Identified 262 patients in claims data with retained foreign                     Identified a larger control group of similar patients who
 object diagnostic codes.                                                         did not have retained foreign object codes.

            • Reduced to 236 cases (-10%) to account for                                                      • Calculated the total

                                                                           -
                potential false positives                                                                       average cost of their health

   !        •                                                                                                                                          = $2.4 million*
                Estimated 224 errors based upon 95% probability                                                 insurance claims during the
                that the event was preventable                                                                  same 1-year period
            •   Calculated the total average cost of these patients’                                                                                        EXCESS HEALTH CARE COST
                health insurance claims 1-year post-event                                                                                                   ATTRIBUTABLE TO ERROR

        ($) Average costs 1-year after encounter                                        ($) Average costs 1-year after encounter
                                                                                                                                                             *Adjusted to 2017 dollars.

                                                                                                                                                                         CONTINUED ON NEXT PAGE

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                                  ©2019 Betsy Lehman Center for Patient Safety   l   5
Two new studies look beyond existing reporting systems to fill important gaps in
   what we know about the costs of medical error
                                                                                                         WHO DID WE SURVEY, AND WHAT DO THEY
II. THE HUMAN COST OF MEDICAL ERROR                    A total of 988 people reported medical error      KNOW ABOUT MEDICAL ERROR?
                                                       experience in the Massachusetts Health
• Question—How does the Massachusetts public                                                             Studies consistently show that patients and
                                                       Insurance Survey. In 2018, we were able to
  experience medical error? Specifically, if we ask                                                      families are excellent observers of medical error.
                                                       conduct a 30-question “re-contact survey”
  a large, randomized cross-section of our state’s                                                       In some cases, they are more likely than their
                                                       with 253 respondents about the physical,
  residents about their experiences with medical                                                         clinicians to detect errors, and are correct most of
                                                       emotional, behavioral, and financial impacts of   the time when they do report errors. But they are
  error, what will we learn about:
                                                       the errors, as well as the communication and      often reluctant to speak up or come forward out of
  ── The incidence and types of medical errors?        support offered by providers after the errors.    a fear of offending their clinicians or out of a belief
  ── The health care settings where errors are         Ten of the re-contact survey questions allowed    that their concerns won’t be taken seriously or
                                                                                                         make a difference.36,37
     happening?                                        for open-ended narratives through which
                                                       we gathered the details of these individuals’     We found that most people are willing to discuss
  ── The physical, emotional, and financial                                                              their experiences when asked. In the initial
                                                       experiences; the narratives were coded for the    survey, 736 of the 988 respondents who told us
     consequences of error to patients and families
                                                       Center by a team of physician researchers at      they had experienced medical error agreed to be
     over time?
                                                       Yale University.                                  re-contacted for in-depth interviews. Of the 253
  ── How providers respond after an error (e.g., do                                                      we were able to reach, everyone was older than
     they disclose, apologize, offer help)?            The re-contact survey also reached 371            18, and the oldest was 91. Almost one quarter of
                                                       respondents who had reported no recent            these individuals live in households earning less
  ── The impact of open communication about            experience with medical error to ask a brief      than 139% of the federal poverty level; nearly half
     errors on patient and family wellbeing?           set of questions regarding their perceptions of   had incomes equal to or greater than 400% of the
                                                                                                         federal poverty level. Over one in three live in a
• Approach—We identified and interviewed               the health care system and patient safety [see
                                                                                                         household where someone has a four-year college
  Massachusetts residents who have experienced         Appendix B for a detailed explanation of the      or advanced degree. Over 40% of the respondents
  medical error through two statewide                  methodology].                                     were men and nearly 60% were women.
  telephone surveys. First, the Center for Health      All survey data and quotes contained in this      The largest group told us about errors that had
  Information and Analysis’ 2017 Massachusetts                                                           happened in their own care (33%). Others told us
                                                       report reflect the respondents’ views of their    about errors in the care of their parent (16%), child
  Health Insurance Survey, which reached 5,001         experience with medical error at the time of      (15%), spouse (12%) and other family members
  randomly selected households, included a brief       the survey.                                       (25%). Of the 67% who said the error happened
  set of questions to identify people who had                                                            to a family or household member, over one in
  experienced a medical error in the previous five                                                       four (27%) were responsible for making decisions
  years in their own care or in the care of a family                                                     about that person’s care when the medical error
  or household member.                                                                                   occurred.
                                                                                                         One in three (33%) respondents reported
  “Sometimes when people receive medical care, mistakes are made.                                        experiencing multiple medical errors in the past
                                                                                                         six years. We asked these people to focus in
  These mistakes sometimes result in no harm; sometimes they may                                         on the single error they remembered best when
  result in additional or prolonged treatment, disability, or death.                                     answering our survey questions.

  These types of mistakes are called medical errors.”
                                  HOW “MEDICAL ERROR” WAS DEFINED IN THE SURVEY33

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                               ©2019 Betsy Lehman Center for Patient Safety      l    6
1 in 5 Massachusetts residents report
Key findings                                                                                                                                         !                     recent experience with medical error
                                                                                                                                                                           either in their own care or in the care of a family member, 2013-2018

                                                                                                                                 OPEN COMMUNICATION BY PROVIDERS IS LINKED WITH LOWER LEVELS OF HARM
    MOST PEOPLE ARE DISSATISFIED WITH
                                                                                                                                                 FEEL                SAD                 DEPRESSED              ANGRY                 AVOID              AVOID
    COMMUNICATION AFTER AN ERROR                                                                                                                 ABANDONED                                                                            FACILITY           DOCTOR
                                                                                                                                                 OR BETRAYED
                                                                                                                                                                                                                                  80%                 78%
                                                                                                                                    80
                                                                                33%                                                 70
                                                                              SATISFIED                    61%
                                                                                                                                    60                                                                     50%
                                                                                                           NOT                      50                           39%
                                                                                                         SATISFIED                  40 OPEN 36%
                                                                                                                                   WITHOUT                                          33%
                                                                                                                                                                                                                                                      30%
                                                                                                                                 COMMUNICATION
                                                                                                                                    30                                                                                            21%
             6%
    DON’T KNOW/
                                                                                                                                    20
                                                                                                                                                                                    4%                     7%
        REFUSED                                                                                                                     10WITH OPEN 0%
                                                                                                                                                                 3%
                                                                                                                                      0
                                                                                                                                 COMMUNICATION

    ERRORS HAVE LONG-LASTING IMPACTS                                                                                             MEDICAL ERRORS LEAD TO A LOSS                       MANY PEOPLE EXPERIENCE FINANCIAL SETBACKS
    ON PHYSICAL HEALTH
        0                               5                                10                15       20       25      30          OF TRUST IN HEALTH CARE                             FROM MEDICAL ERRORS
        0                               5                            10                    15       20       25      30

    NO CHANGE
        0                               5                            10                    15       20       25      30

                                                                                                                                                     66% LESS TRUSTING
                                                                                                                                                                                                        33%                                        50%
                                                                                                                           100

0
    0
                                    5
                                     5                              10
                                                                    10
                                                                                          15
                                                                                          15
                                                                                                   20
                                                                                                   20
                                                                                                            25
                                                                                                            25    27%
                                                                                                                    30
                                                                                                                   30

    0                                5                               10                   15       20       25      30

    SLIGHT IMPACT
                                                                                                                            80
                                                                                                                                                                                                        DECREASE                                   INCREASED
FINDING:      Medical errors are frequent, harmful, and costly

Using one year of claims from the state’s APCD and    Of the 98 types of errors that can be found in
Medicare data from 2013,32 we identified 42,927       claims data, the top 10 most frequent errors                THE TOP 10 MOST FREQUENT ERRORS
preventable harm events that happened in settings     account for 71% of all errors. Seven of the top 10
that provide services covered by health insurance,    most frequent errors were also among the top 10             1. Pressure ulcer ($)*                            14,369
primarily hospitals, ambulatory surgery centers,      most costly errors.                                         2. Postoperative infection ($)                     4,625
medical offices, and nursing homes. During the                                                                    3. Infection and inflammatory                      1,919
                                                      Our findings about the most frequent types
12 months following each error, we also identified                                                                   reaction due to internal prosthetic
                                                      of errors follow a pattern similar to the earlier
$518 million in excess health insurance claims                                                                       device implant and graft ($)
                                                      national study on which it was based, with seven
associated with patient harm. For several common                                                                  4. Bleeding/blood loss (hemorrhage)                1,628
                                                      of the most frequent errors making the top 10 lists
preventable harm events that cannot be fully                                                                         complicating a procedure
                                                      in both studies.31 Such alignment suggests that
identified in claims data or that the established
                                                      not only do Massachusetts providers face many               5. Chronic pain after back surgery                 1,606
methodology did not account for—falls, medication
                                                      of the same safety challenges as their national
errors, MRSA and C. difficile infections—we were                                                                  6. Accidental puncture or laceration               1,511
                                                      counterparts, but that the methodology from the
able to supplement the incidence figures with                                                                        during a procedure ($)
                                                      national study is valid as applied to Massachusetts.
partial data from peer-reviewed studies and
                                                      Our cost findings are, in turn, reinforced by the           7. Medical treatment-induced                       1,367
incident reports related to hospital inpatient                                                                       abnormally low blood pressure
                                                      results from our survey of Massachusetts residents.
admissions,38-48 and apply other established cost                                                                    (Hypotension Iatrogenic) ($)
                                                      Nearly two-thirds of survey respondents who
estimates for these conditions.49 This added 19,055
                                                      reported experience with medical error also                 8. Substances causing adverse effects              1,238
incidents and $99 million in excess costs to our
                                                      reported that the error resulted in a need for                 in therapeutic use ($)
calculations.
                                                      additional care, including longer hospital stays,
Overall, we found 61,982 preventable harm events      rehabilitation services, or extra doctor visits.            9. Abnormal collection of blood                    1,224
and over $617 million in excess health insurance                                                                     (bruise/contusion) complicating a
                                                                                                                     procedure ($)
claims—just above one percent of the state’s Total
Health Care Expenditures.50                                                                                       10. Ventral hernia without mention of               948
                                                                                                                      obstruction or gangrene

                                                                                                                  ACCOUNT FOR 71% OF ALL ERRORS
                                                                                                                  IDENTIFIED IN CLAIMS DATA

                                                                                                                                                  71%
                                                                                                              0            20          40           60         80            100

                                                                                                             *($) Also one of the top 10 most costly errors.

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                        ©2019 Betsy Lehman Center for Patient Safety        l    8
Our incidence and cost calculations are conservative estimates

If we were able to analyze claims data from 2018, it is possible that we would find some change in the total incidence of preventable harm events, either from
improvements that have been documented by several hospital metrics14 or from differences in the way providers now code claims. Nevertheless, we believe that
our approach, combined with the inherent limitations of claims data analysis, has resulted in findings that underestimate the full incidence and financial cost of
medical error in the Commonwealth.

1. We were conservative in our methodology.             3. Health insurance claims data are incomplete.
   • We decreased our counts of diagnostic codes           For example:                                              PATIENTS’ EXPERIENCE OF MEDICAL ERROR
     associated with errors by 10 percent to               • Providers are not entirely consistent in the            SUPPORTS OUR CONSERVATIVE ESTIMATES
     account for potential false positives.                  way they code claims.
                                                                                                                     Around 60 percent of respondents described an
   • We made no such adjustment for potential              • Providers may intentionally code in ways to             error or delay in diagnosis.
     false negatives or missing data.                         avoid pay-for-performance penalties.
                                                                                                                       ──   About two out of three of these errors had
2. Some frequent and costly types of error                 • In a recent study that analyzed both Medicare                  to do with errors in judgment made by
   cannot be easily identified through health                 claims data and patient medical charts to                     clinicians, such as failure to perform simple
                                                                                                                            diagnostic tests.
   insurance claims. Data only reveal what a                  identify pressure ulcers, researchers found
   patient was treated for—not the underlying                 that chart review caught about 20 times more             ──   About one out of three events stemmed
   reasons for the treatment or whether the                   pressure ulcers than claims data analysis.53                  from process breakdowns, such as a
                                                                                                                            critical lab or radiology result that was not
   treatment was correct or timely; this precludes      4. Our analysis misses costs that are not                           communicated.
   us from comprehensively including several               reimbursed through primary health insurance,              Nearly half of respondents (49%) reported two
   known leading causes of patient harm,                   including—                                                or more financial impacts from medical error
   including:                                                                                                        such as:
                                                          • Costs of services covered through other types
   • Diagnostic error and delay in all health care           of insurance (e.g., retail pharmacy, most                 ──   Increased medical expenses (50%)
      settings7,52                                           dental)                                                   ──   Missed time at work (32%), leaving a job
   • Preventable patient falls in non-hospital            • Malpractice claims payments                                     (21%), or decreased income (33%)
     settings43                                                                                                        ──   Extra household expenses (33%)
                                                          • Economic and quality of life costs
   • Medication errors in non-hospital settings   6
                                                          • Other human toll

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                          ©2019 Betsy Lehman Center for Patient Safety         l   9
Medical errors happen in all health care settings throughout Massachusetts
    FINDING:
    and can happen to anyone
Public perception of medical error as a problem in          Our re-contact survey of the 253 Massachusetts                                 The age of the patient to whom the medical error
Massachusetts is low. A majority of all respondents         residents who completed in-depth interviews                                    happened ranged from less than one to over 90.
(including the group that did not have recent               about their medical error experiences shows that                               Although median age at the time of the error was
experience with medical error) believe that medical         errors happen in all health care settings, including                           53 years old, 15% of the errors described occurred
error is not a problem (59%) or do not know (7%).           nursing homes, dental offices, emergency rooms,                                to patients less than 18 years old and 18% of the
However, of those who report it is a problem,               hospitals, urgent care, prison infirmaries, primary                            errors occurred to respondents 75 or older.
78% feel it is a serious problem. These findings are        care practices, and retail pharmacies.
virtually identical to those from a statewide survey
                                                            People who reported medical errors live in every
conducted five years ago.34                                 part of the state. No inferences can be made
Similarly, over half (55%) do not believe a medical         about the relative safety of health care in different
error is likely in their own future care. But knowledge     regions because we only asked people where they
of past medical errors increases respondents’ sense         live, not where their errors occurred.
of personal risk. Almost two-thirds of respondents
(63%) who were aware of two or more medical                                    Frequency
errors in their own or other people’s care believed         MEDICAL
                                                              35    ERRORS HAPPEN IN ALL HEALTH CARE SETTINGS ...
that a future medical error was likely.
                                                                      30
                                                                                                                            ................................................... HOSPITAL (NOT ER) 41%
DOES THE MASSACHUSETTS PUBLIC SEE                                     25
MEDICAL ERROR AS A PROBLEM?                                           20           ................................................................................................ EMERGENCY ROOM 15%
                                                                      15                            ............................................................. DOCTOR’S OFFICE OR CLINIC 27%
                                                                      10
                NO 59%
                                                                       5
                                                                                     ................................................................................................................ OTHER* 17%
                                                            *E.g.,0pharmacy, dentist, nursing home
                                                                           0             20                      40                       60                       80                      100
                                   DON’T
                                   KNOW 7%
                  YES 34%                                               Frequency
                                                            ... AND TO PEOPLE OF ALL AGES
                                                                      35
                                                          FREQUENCY

    100                                                                                                                                                                             > 80 YEARS
                                                                      30
              78% of these
     80                                                               25
              people believe
     60       medical error                                           20
              is a serious                                            15
     40
              problem                                                 10
     20
                                                                       5
      0                                                                0
                                                                           0               20                       40                         60                        80                       100
                                                                                                                                                                                       AGE (YEARS)

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                                       ©2019 Betsy Lehman Center for Patient Safety                   l   10
Medical errors are associated with long-lasting physical and emotional
       FINDING:
       impacts
  Survey respondents described significant,                Medical error also was associated with long-lasting                  “The hardest one right now is dealing with the
  persistent physical harms from medical errors            emotional health impacts. Among respondents                           medical issues, the extra bills for the medicines. I
         10       20        30       40     50       60       70 reported
                                                                        80 that the error happened three to
0
  that had happened as many as six years before            who                                                                   just get stressed out constantly. And I am furious
  the survey.* Almost 30% stated that their physical       six years before the survey, one-third reported                       because this is the mess they created and they just
  health (or the physical health of the household          that they still feel anxious, more than a quarter                     threw me out the door, which was even worse.”
  or family member to whom the error happened)             continue to feel sad, angry, and just over one in five                                       – She suffered complications from
  was impacted at least to some degree for one year        say they are DEATH
                                                                            depressed. Respondents who reported                                                   an unnecessary surgery
  or more. An additional 12 percent were familyHEALTH STRONGLY
                                                           an error>three
                                                                        1 YEAR to six years earlier were also the
  members of a person who reportedly died.                 most likely to feel as if they had been abandoned
                                                        HEALTH STRONGLY <
                                                           or betrayed by the providers involved. The only
  On the opposite end of the spectrum, over one
                                                           emotional
                                                         HEALTH          impact
                                                                   SLIGHTLY    > that seems to steadily subside                 “It was quite painful. Well I had anxiety for quite a
  in four respondents indicated that the error had
                                                           over time is anger.                                                   while, and I think depression, and overall, a loss
  no physical health impact at all. This suggests that HEALTH SLIGHTLY < 1                                                                                                                            ME
  respondents   can                                                                                                              of faith.”
                  20 identify
                            30errors 40
                                     when harm
                                            50 did not       Because
                                                              70 NO the 80re-contact survey took place almost one year
                                                           *
         10                                          60               CHANGE
0 result, such as a retail pharmacy dispensing error       after the larger statewide survey that identified people who              – An error during a home care visit necessitated an
                                                           reported having experienced medical errors during the                                            additional painful procedure
  where the person caught the mistake before taking        previous five years, the reported errors occurred up to six
  the wrong medicine.                                      years prior to the re-contact survey.
                                                                                           0       10          20          30            40             50          60          70        80
         10         20        30        40    50       60        70        80
0
    MEDICAL ERRORS HAVE LONG-LASTING                          MEDICAL ERRORS HAVE LONG-LASTING IMPACTS ON EMOTIONAL HEALTH
    IMPACTS ON PHYSICAL HEALTH
    NO CHANGE                                                                                                               29%                ERROR

                               27%                                    Still depressed
                                                              STILL DEPRESSED                                 16%                              OCCURRED
                                                                                                                    21%                             Less than 1 year ago
                                                                                                                                                    1 to 2 years ago
    SLIGHT10
           IMPACT 20          30        40     50       60       70       80                                              26%                       3 to 6 years ago
 0
NO CHANGE

              FINDING:Medical errors are associated with long-lasting loss of trust and avoidance of
              health care                         LESS TRUSTING

         An experience with medical error is likely to have lasting effects on an                     Well over half of the respondents whose error happened 3-6 years ago say that they
         individual’s attitudes and behaviors regarding the health care system.                       sometimes or always continue to avoid the doctors or the health care facility involved
         Two-thirds of respondents expressed reduced levels of trust in health                                         0
                                                                                                      in the error. Of even   10 concern
                                                                                                                            greater  20      30 more
                                                                                                                                          is that   40 than one-third
                                                                                                                                                            50      60of all respondents
                                                                                                                                                                              70      80     90
         care no matter how long ago the error occurred.                                              report that they continue to sometimes or always avoid all medical care.

         MEDICAL ERRORS CAUSE LONG-LASTING LOSS OF TRUST IN                                                PEOPLE OFTEN AVOID HEALTH CARE FOR A LONG TIME AFTER
         HEALTH CARE                                                                                       AN ERROR
                                                                    ERROR                                                                                             50%
                        1%
                                                                    OCCURRED
           More                                                                                    Still avoid                                                                    64%
TRUSTINGtrusting         3%                                           Less than 1 yearSTILL
                                                                                      ago AVOID DOCTORdoctor
                         3%                                           1 to 2 years ago                                                                                      57%
                                                                      3 to 6 years ago

                                                  31%                                                                                                           45%
            No                                                                                           Still avoid                                                              64%
O CHANGEchange                                      35%                                  STILL AVOID FACILITYfacility
                                                                                                                            MEDICAL ERRORS CAUSE LONG-LASTING LOSS OF TRUST IN HEA
                                              29%                                                                                                                           57%

                                                                                 67%                                                                            45%
                                                                                                   Still avoid
             Less                                                                                   medical                                           34%
TRUSTINGtrusting                                                              STILL AVOID MEDICAL CARE
                                                                            62%
                                                                                                          care
                                                                                67%                                                                      37%

                    0         10    20       30         40     50      60         70          80      90      100       0      10       20       30      40        50       60       70         80        90   1

         “I stay away from medical [care]. I stay                      The hardest part is the cynicism and
          away from it as much as possible. I use                       guardedness I continue to have for everyone                            “I feel the humanity is being
          alternative resources; try and go holistic.”                  in the medical field. I have no trust left.”                            taken out of the process.”
                    – Repeated hospitalizations from a surgical                                – A clinician refused to reconsider a         people often
                                                                                                                                                – Her     avoid
                                                                                                                                                      husband hadhealth
                                                                                                                                                                  trouble care for aand
                                                                                                                                                                          breathing  long  time after a
                                                                                                                                                                                        ended
                     error put this mother of young children out                           diagnosis that turned out to be incorrect,              up in the emergency room after a missed
                     of work for months                                                         leading to additional complications                diagnosis at his doctor’s office earlier in the day
D DOCTOR

D FACILITY

         THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                           ©2019 Betsy Lehman Center for Patient Safety    l   12
FINDING: Patients                  and families rarely receive an apology or offer of support following a
    medical error
Despite a Massachusetts law54 that requires                                                                                  100

providers to disclose medical errors that cause                                                                               80
                                                                                                                                           Sincere 82%
significant harm and encourages apology, more                                                                                 60
                                                                                                                                           Majority who received apology felt it was sincere.
than 60 percent of respondents expressed overall
                                                                                                                              40
dissatisfaction with how providers communicated
in the aftermath of an error.                                                                                                 20

Fewer than one in five (19%) of respondents say                                                                                0

that they received an apology after the medical                                                                   Fewer than one in five
                                                                                                              say they received apology
error. Most people (82%) who did receive an                                                                     following medical error.
apology felt it was sincere.

Only one quarter (25%) of respondents were no support                                                                                             ..................... NO SERVICES OFFERED 75%
offered one or more types of emotional, functional,
                                     psychological
or financial support services. The most    common  counseling                .............................. PSYCHOLOGICAL COUNSELING FROM A MENTAL HEALTH PROFESSIONAL 8%
additional help offered among all respondents spiritual                            ..... SPIRITUAL SUPPORT, SUCH AS FROM A CHAPLAIN OR OTHER RELIGIOUS ADVISOR 13%
reporting experience with a medical error was                                                                                                                                                    MEDICAL ERRORS CAUS
                                                 social worker                  ................................................................................................ HELP FROM A SOCIAL WORKER 11%
spiritual support (13%). The setting in which their
error occurred (e.g., hospital or helping
                                  medical   office)
                                          paying outdid
                                                     of pocket           ............................................................... HELP PAYING OUT OF POCKET OR OTHER MEDICAL COSTS 3%
not significantly change the likelihood of receipt of
                                        money to compensate             ..... MONEY TO COMPENSATE YOU/THEM FOR INJURIES RESULTING FROM THE MEDICAL ERROR 2%
an apology or offer of assistance.

                                                                 0.000000 10.62500121.25000231.87500342.50000453.12500563.75000674.375007
Among the 28 percent of respondents who                               Did provider explain any follow-up actions                      Did provider offer information about a review or
                                                                      to prevent similar errors in the future?                        investigation to determine what caused the error?
reported receiving an acknowledgment of the error
from the place where the medical error occurred,
23 percent reported also receiving an explanation
of the actions being taken to prevent similar errors
from happening in the future.                                                       NO 72%                                                                NO 86%

                                                                                               YES 23%                                                                            YES 9%
                                                                                                                                                                                                    people oft

                                                                                                                                                                             DON’T
                                                                                   DON’T                                                                                     KNOW 5%
                                                                                   KNOW 5%

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                              ©2019 Betsy Lehman Center for Patient Safety         l    13
0.000     10.625      21.250        31.875       42.500       53.125       63.750       74.375       85.000

    FINDING: Most people are dissatisfied with the communication they receive from
    providers after an error
We also asked respondents a series of questions about              MORE THAN 60 PERCENT OF PATIENTS AND FAMILY MEMBERS ARE
six elements of communication:                                     DISSATISFIED WITH CARE TEAM COMMUNICATION AFTER AN ERROR
                                                                                                                                                                                               p
                                            COMPLETELY
Did anyone at the place where the medical error                                    ..................................................................... COMPLETELY SATISFIED 15%
occurred…
                                         SOMEWHAT SAT                               ..................................................................... SOMEWHAT SATISFIED 18%
1. Acknowledge the error?
And did anyone on the care team...          SOMEWHAT DIS                              ............................................................. SOMEWHAT DISSATISFIED 13%
2. Speak openly and truthfully about the error?
                                               NOT AT ALL                                                                  ..................... NOT SATISFIED AT ALL 48%
3. Speak about the error in an easy to understand way?
4. Provide information needed to understand the health
                                                 DUNNO                    ................................................................................. DON’T KNOW/REFUSED 6%
   effects of the error?
5. Offer a chance to ask questions about the error?
                                                                  0                 17                   34                   51                   68                   85
6. Offer a chance to express feelings about the error?             OPENNESS OF COMMUNICATION BY PROVIDERS VARIES AFTER AN ERROR
One out of three respondents answered “no” to 5-6 WAYS                                          .......................................... COMMUNICATED IN 5-6 WAYS 24%
all six questions, reporting that they received no
communication whatsoever (the “no communication
                                                         3-4                   .............................................................. COMMUNICATED IN 3-4 WAYS 11%
group”). However, nearly a quarter of the respondents
                                                                                                                                                                                    MEDICAL ERRO
answered “yes” to five or all six of these questions,
                                                         1-2                                           ................................. COMMUNICATED IN 1-2 WAYS 30%
reporting that their care teams shared information about NOT
the error and invited further discussion in multiple ways
(the “open communication group”).                   NO COM                                                 ........................................ NO COMMUNICATION 34%
                                         SOMEWHAT DIS
                                                                0.000     10.625       21.250       31.875       42.500       53.125       63.750       74.375        85.000

“Well, first thing [that would have helped] would    “I guess the thing that made it worse was that there                        “Any acknowledgment of their mistake, or
 have been to acknowledge and apologize that          was zero communication with them. Zero.”                                    a recognition that they need to be better
 mistake had been made. And I think secondly, I                           – Her mother’s physician did not relay                  listeners, would be nice.”
 did incur out-of-pocket costs to have the procedure                 information about a critical heart condition
                                                                                                                                                  – Clinician failed to recognize
                                                                              identified in tests he had ordered
 done again, and those should have been covered.”                                                                                                  seriousness of infection despite
                                                                                                                                                   patient’s concerns, delaying treatment
                – He had to have a second procedure
                 because of an error
                                                                                                                                                                                               p
                                              COMPLETELY

                                           SOMEWHAT SAT
THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                                       ©2019 Betsy Lehman Center for Patient Safety      l   14
FINDING:For people who receive it,STILL
                                         open      communication is associated with lower
                                            DEPRESSED

    levels of adverse emotional health impacts and health care avoidance55
                                                                              STILL SAD

Open communication is linked to lower emotional           WHEN PROVIDERS COMMUNICATE OPENLY, EMOTIONAL HARM IS ALLEVIATED
harm. While up to half of respondents in the no                STILL FEEL ABANDONED                           4%                                                         Open communication
communication group still felt sad, depressed,                        STILL DEPRESSED
                                                                               Still depressed                                                    33%                    No communication
anxious, angry, or abandoned or betrayed at
the time of the re-contact survey, the open                              STILL ANXIOUS                        3%
communication group reported lower levels of                                  STILL SADStill sad                                                         39%
all of these emotional impacts—and no lingering
feelings of abandonment and betrayal.                                      STILL ANGRY                   0%
                                                               STILL FEELStill feel abandoned or
                                                                          ABANDONED
                                                                               betrayed by doctor                                                     36%
While anxiety appeared to be lowered by open
communication, that finding was not statistically                                                                                      23%
significant, suggesting that there are additional                                  Still anxious
                                                                         STILL ANXIOUS                                                                  37%
                                                                                                     0                     17                    34               51                68                8
challenges to regaining confidence in the health
care system following a medical error experience.                                                                  7%
                                                                                    Still angry
                                                                           STILL ANGRY                                                                             50%
The effects of open communication remained
significant for sadness and feeling abandoned or
betrayed by doctors when we controlled for how
long ago the error occurred, physical and financial
                                                          OPEN COMMUNICATION ALSO ALLEVIATES
                                                                                   0         HEALTH
                                                                                              17    CARE AVOIDANCE
                                                                                                          34                                                      51                68                8
severity of the error, and a number of other
potential influences.56                                                                                                                    30%
                                                                 STILL AVOID Still
                                                                             DOCTORavoid doctor
                                                                                                                                                                                         78%
Open communication can also reduce health care
avoidance. The open communication group was
significantly less likely to avoid both the doctors                                                                              21%
                                                                  STILL AVOID Still
                                                                              FACILITY
                                                                                    avoid facility
and the health care facility involved in the error                                                                                                                                          80%
when controlling for the same potential influences
discussed above. Avoidance of medical care in                                                                                          26%
                                                                 STILL AVOID DOCTOR
general also declined for the open communication           STILL AVOID Still avoid CARE
                                                                       MEDICAL     medical care
                                                                                                                                                            45%
group, but not to a statistically significant degree.57

                                                                  STILL AVOID FACILITY
“And he even came in and apologized to me.                “I had an OB-GYN who was so phenomenal.
                                                                                            0.0    9.5 At19.0
                                                                                                           the end28.5
                                                                                                                   of my 38.0
                                                                                                                          pregnancy,
                                                                                                                                 47.5 he was
                                                                                                                                         57.0 like,66.5
                                                                                                                                                    ‘I need76.0
                                                                                                                                                            to call 85.5                              95
 And I’ve never had a doctor do that.”                     somebody else because I want somebody else to agree or disagree with me.’ And I thought to myself, ‘I
            – Her bowel obstruction was missed             have such respect for this man,’ because he could say that on his own.”
             during an emergency department visit          STILL AVOID MEDICAL CARE
                                                                                                                    – She compared an earlier experience to a more recent one involving
                                                                                                                                                  poor communication with a physician

THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR
                                                                                                 0.0               9.5    19.0         28.5©201938.0     47.5   57.0       66.5      76.0
                                                                                                                                                 Betsy Lehman Center for Patient Safety l
                                                                                                                                                                                               85.5
                                                                                                                                                                                              15
                                                                                                                                                                                                      95
Patients and families are astute observers of what happened and why things
    went wrong
                                                                                                              “All I’m trying to say is that I’ve become acutely
When answering a series of open-ended                   UNDERLYING CAUSES OF THE ERRORS
questions about the errors they had experienced,                                                               aware that in an age of increased specialization,
the 253 re-contact survey respondents described         SYSTEMS FACTORS                                        the biggest challenge is the patient has to take
what happened and their perceptions of the
                                                        The absence of precautions or other fail-safes for     responsibility for communication across all
underlying causes of those events. They also                                                                   specialties.”
                                                        preventing harm was a common theme among
shared ideas for preventing similar events from                                                                       – She was advised to undergo an unnecessary
                                                        our survey respondents. These breakdowns
happening again. Several major themes emerged                                                                         surgery when her symptoms were mistaken for
                                                        included issues related to equipment maintenance,                                   something more serious
from these narratives.                                  oversight of clinician and staff hand hygiene
CHARACTERISTICS OF THE ERRORS                           practices, and systems for preventing patient
                                                        misidentification.                                    “You should not confuse one individual with
Although our sample included many cases of
severe injury in the course of more intensive           COMMUNICATION FACTORS
                                                                                                               another. Between social security numbers,
treatment, survey respondents often described                                                                  addresses, previous addresses, guarantor on
                                                        Another major theme expressed by respondents
preventable injuries that happened in the course of                                                            the account, everything else that they ask you. I
                                                        was that they were dismissed or not heard when
routine care, such as:
                                                        trying to alert care team members that they had        found it very difficult to understand.”
• A child given injections intended for another         known reactions to a proposed medication, were                     – Her son’s medical records are entangled
   child in a pediatrician’s office                                                                                                             with another patient’s
                                                        at risk of falling, or their symptoms did not align
• Extraction of the wrong tooth in a dentist’s office   with the doctor’s diagnosis.
• An infusion overdose in a nursing home
                                                        Unclear or incomplete discharge and follow-up         “I know she was sick and I know she wasn’t
Moreover, while patient harm can sometimes              instructions to patients were another frequent         going to live another 10 years. I get all that. A
result from a singular error, it is often the by-       concern. More than a few respondents reported
product of a series of cascading events combined                                                               little bit of reasonable follow-through would’ve
                                                        hesitating to seek additional help as their health
with missed opportunities to prevent injury. One                                                               prevented so much.”
                                                        worsened because they were given reassurances
woman reported undergoing surgery to remove             that they were fine during an urgent care or                     – This nurse’s mother’s health deteriorated
kidney stones based upon a misread radiology                                                                            during a nursing home stay from a series of
                                                        emergency department visit but no information                communication breakdowns and other missteps
report (no stones were found), only to have her         about what should prompt them to seek help again.
appendix accidentally nicked, resulting in additional
surgeries, a post-operative infection and more.         Many respondents perceive the health care             “So I have to go to consult a specialist at another
                                                        system as fragmented. They pointed to various
                                                                                                               hospital and open up, basically, a new system of
                                                        breakdowns in teamwork or communication
“I’m sure they’re strapped. They’re working hard,       among clinicians and staff at a single organization    medical records, because the original hospital and
 too. [But] that’s just poor discharge planning.”       or between health care organizations as they           this hospital don’t talk to each other.”
           – She was caring for a relative who was
                                                        moved across the care continuum as contributors                    – A well-known complication of his medical
          discharged with medications the provider      to the errors they experienced.                                          condition was missed by a physician
          should have known he could not swallow
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THE FINANCIAL AND HUMAN COST OF MEDICAL ERROR                                                                      ©2019 Betsy Lehman Center for Patient Safety   l   16
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