Following the release of the Institute of Medicine report (To Err is Human) on medical errors in 2000, the Center partnered with the Massachusetts Division of Health, the Massachusetts Hospital Association, the Harvard School of Public Health, and the Massachusetts General Hospital on a multi-faceted study to explore the error reporting issues at both the state and hospital levels.

One phase of the study involved data collection from an assortment of hospital administrators at acute care hospitals across six states (Massachusetts, Pennsylvania, Georgia, Florida, Texas, Colorado). Hospital CEO/COOs, Medical Directors, Risk Managers, and Patient Safety Officers were pursued for telephone interviews about their current hospital error reporting practices as well as their feelings about various error reporting options.

A second phase of data collection was focused on the patient view of medical errors. More than 2500 patients were interviewed by telephone about a recent hospital stay. When the patient indicated that an adverse event might have happened during their stay, additional questions were asked to flesh out the details. When the data were analyzed, they provided insights to the contributions patients can make regarding the identification and proper handling of medical errors.

In a third phase of this project, CSR helped evaluate the success or failure of two Massachusetts interventions to reduce medical errors in hospitals. The first intervention was focused on decreasing medication errors both while the patient is in the hospital and after the patient is released. A systems approach was used to encourage hospitals to improve their methods for reconciling patient medications upon entry into the hospital and then again upon patient discharge. The second intervention was to improve the handling of critical test results between those in the Lab, Radiology Department, or Cardiology Department, who first produce the critical finding, and the practitioners providing patient care who need to act on the finding. The leaders of the hospital implementation teams for each intervention, as well as the hospital CEO, were provided self-administered questionnaires to allow them to provide feedback on the success of each intervention.