December 14, 2001

MGHers are invited to two upcoming events addressing the subjects of patient safety and medical errors. "Lessons Learned from the Veterans’ Administration Patient Safety Effort" will be presented by Jim Bagian, MD, director of the Veterans Administration National Center for Patient Safety, Dec. 17, from 3 to 4 pm in the Walcott Rooms. "Who’s Responsible for your Mistakes?" will be presented by Lucian Leape, MD, of the Harvard School of Public Health, Dec. 20 from 8 to 9 am in O’Keeffe Auditorium.

With a long-held commitment to continuously improving the quality and safety of patient care at the MGH, a group of more than 100 hospital leaders met Oct. 31 to discuss related issues and outline plans for the coming year. Participants in the half-day retreat, which was held at the Royal Sonesta Hotel in Cambridge, included chiefs of service, administrators, members of quality committees and clinical performance management teams from throughout the hospital.

Hosted by the MGH Office of Quality and Safety, the retreat focused on four key areas: reviewing the function of the Quality Assessment Committee; determining requirements for reporting incidents to external organizations; initiating proactive quality programs; and developing performance/competency-based credentialing requirements for clinicians.

Guest speaker Howard Koh, MD, director of the Massachusetts Department of Public Health (DPH), spoke about the strong public safety system in Massachusetts and the challenge faced by the medical field in preventing clinical errors. "The concern about making mistakes is overwhelming for health care professionals," he said. "The expectations of the public, scrutiny by the press and our own reactive responses to errors have created a culture of fear. We need to change the culture to one of safety. We also need to provide support in our own systems so that clinicians who are well-intentioned don’t make mistakes."

Koh cited the nearly $8 million in federal funding that Massachusetts organizations have secured to study medical error prevention. Ten of the 94 grants awarded throughout the country were given to local organizations such as the DPH, MGH and BWH. "We are living in unprecedented times now," Koh said. "We are poised to make dramatic changes in the quality and safety of health care in Massachusetts."

The tone of the retreat exemplified the MGH’s commitment to bringing about change. "The MGH is well known as a leader in education, research and patient care," said Brit Nicholson, MD, chief medical officer of the MGH. "We also should be looked to as a leader in the area of quality and safety."

The additional retreat speakers – Jeanette Ives Erickson, RN, MS, MGH senior vice president for Patient Care Services and chief nurse; Peter Slavin, MD, CEO of the Massachusetts General Physicians Organization (MGPO); and Jim Richter, MD, medical director of the MGPO – all encouraged participants to communicate to their departments the importance of developing systems and programs focused on quality and safety that support staff in their everyday practice.

"Now is the time to act," said Richter. "Quality is fundamental to our mission. We must define it, measure it and implement a system with substance to pursue our vision of quality health care. We should transition from a culture of placing blame to one of support, and we should breathe new energy into our quality improvement efforts."