The Financial and Human Cost of Medical Error - on Patient Safety ... and How Massachusetts Can Lead the Way - Betsy Lehman Center
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The Financial and Human Cost of Medical Error
... and How Massachusetts Can Lead the Way
on Patient Safety
JUNE 2019
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
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
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 iiAbout 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 1Medical 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 2Progress 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 3What 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 4Two 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 5Two 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 61 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 INCREASEDFINDING: 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 8Our 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 9Medical 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 10Medical 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
0NO 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 12FINDING: 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 130.000 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 14FINDING: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
95Patients 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
CONTINUED ON NEXT PAGE
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