July 20, 2001

Issues of quality and safety in health care recently have been making headlines in the media. Among the latest reports was the announcement of new rules set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that require hospitals to tell patients if they have been harmed as a result of a medical error. While there now is a nationwide focus to raise the bar of expectations for quality and safety measures in hospitals across the country, that focus already has been present at the MGH for years.

According to Cy Hopkins, MD, of the MGH Office of Quality and Safety (OQS), the hospital's policy about adverse events and medical errors has long been in line with the new JCAHO standards. The hospital's policy recently was revised, however, to include more explicit details that will help support efforts to maintain a safe environment for all patients, staff and visitors.

The revised policy encourages employees to promptly report any incident or potential incident without fear of negative consequences for initiating the report. Appropriate action will be taken to manage the incident, with the welfare of the patient given priority. The policy states that caregivers have a professional and ethical obligation to inform patients and their families about incidents that may have affected their care. Employees and staff members can work with their clinical supervisors, OQS staff or the chairs of the Quality Assessment Committee to receive help with this kind of communication.

Staff of the OQS, which was established by MGH leadership last fall, currently are informing and educating MGH clinicians about the revised policy. "We want to make sure that hospital staff are aware of the revised policy, which was made more explicit to give more support to our employees. It also gives us an opportunity to learn from these situations and make improvements when needed," says Hopkins.

The revised policy is one of several initiatives that are being introduced by the OQS to help establish a culture of safety at the MGH. OQS staff members are developing a medication error prevention project that monitors the hospital's efforts in reducing such errors. The OQS is developing a better tracking mechanism for incident report follow-up. They also can provide a root cause analysis for certain incidents to evaluate problems that can be addressed to prevent future occurrences.

For more information about hospital safety policies, call the OQS at (617) 726-9282.