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HD 6116

A communication from the Betsy Lehman Center for Patient Safety (see Section 15 of Chapter 12C of the General Laws) submitting its annual report for calendar year 2025

194th Legislature (2025-2026)

Massachusetts unveils a comprehensive safety roadmap to cut preventable patient harm, using real-time monitoring, statewide education, and statewide reporting to drive improvements

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Bill Summary · HD 6116

Summary of HD 6116 (Session 194th) – Massachusetts Betsy Lehman Center Annual Report for 2025

  • Purpose and intent

    • This bill conveys the Betsy Lehman Center for Patient Safety’s annual report for calendar year 2025, as required by Section 15 of Chapter 12C of the General Laws. The report documents the Center’s activities, findings, and progress under its mission to reduce preventable patient harm and to advance safety across Massachusetts health care settings.

  • Key provisions and content of the report

    • The Roadmap to Health Care Safety: The report outlines Massachusetts’ first-in-the-nation strategic plan to reduce patient harm and improve safety across the health care continuum, organized around informing, incentivizing, and implementing safety improvements.
    • System-wide patient harm: Estimates of the incidence and costs of medical harm in Massachusetts, including:
    • Acknowledgment that about 1 in 4 patients experience some harm during a hospital admission.
    • In 2025, an updated analysis estimates 179,478 patients experience at least one harm event during hospitalizations, with $2.14 billion in excess claims attributable to harm.
    • Harm increases hospital length of stay by about 6.6 days on average, affecting throughput and emergency/ post-acute care demand.
    • Harm occurs outside hospitals (e.g., outpatient settings, clinics, pharmacies, nursing homes); outpatient events accounted for about 7% in a related estimate, with 44% of errors outside hospital settings from a 2019 baseline.
    • Facility-level reportable events (SREs): Discussion of Serious Reportable Events (SREs) reporting to the Massachusetts Department of Public Health (DPH):
    • DPH collects and shares facility-level SRE data; 2024 data show 1,706 SRE reports (all from hospitals).
    • Undercounting and underreporting are highlighted as challenges, with reports noting that many events go unreported or are not recognized as reportable due to factors like workflow, biases, and framing of events.
    • Efforts to raise awareness and improve reporting across settings (e.g., collaboration with the Massachusetts Association of Ambulatory Surgical Centers to broaden reporting to ASCs and “near misses”).
    • Priority Roadmap action steps:
    • Automated adverse event monitoring (AAEM): Pilot program piloted with Massachusetts hospitals using EHR scanning to detect harm in near real time, with goals to shorten detection, improve safety response, and reduce harm. Initial FY26 funding of $895,450 for the AAEM pilot with Pascal Metrics Inc.; expected to publish findings statewide to inform standards.
    • Statewide health care safety curriculum: Development of a first-in-the-nation statewide safety curriculum and educational standards for licensed/certified professionals. First foundational e-learning course planned for 2026.
    • Patient and Family Advisory Councils (PFACs): Continued support and integration of PFACs across acute and rehabilitation hospitals. The report covers PFAC activities, data collection, and impact, including a new annual reporting form and statewide PFAC report highlighting activities, costs, and progress.
    • Programmatic support to providers:
    • Communication, Apology and Resolution (CARe): Expansion of CARe programs to promote transparency, timely communication, cause analysis, apologies, and resolution where appropriate. CARe has 17 partner sites with 491 cases resolved in 2025; CMS safety metrics emphasize transparency as a key safety measure.
    • Peer support: Establishment of a statewide Virtual Peer Support Network and a Patient and Family Peer Support Network to assist clinicians, staff, patients, and families; ongoing training, learning collaboratives, and partnerships with providers to implement and publicize these resources.
    • Interagency initiatives:
    • Advancing safety in long-term care: Creation of an interagency working group (with DPH, MassHealth, EOA, MA Senior Care Association) to develop safety practices in long-term care settings, including all-hazards emergency preparedness and multilingual safety videos; plan to pilot a learning collaborative to share best practices.
    • Maternal health data and improvement: Collaboration on maternal health data for timely SMM (Severe Maternal Morbidity) analysis and improvements. Efforts include standardizing Levels of Maternal Care and improving data timeliness by creating monthly data submissions, SMM analysis, and outreach to hospitals. The report highlights significant racial disparities in SMM and payer-related differences, with Medicaid-insured patients experiencing higher and more rapidly rising SMM rates.
    • Overall impact and outlook: The report emphasizes the Betsy Lehman Center’s role as a convenor, data analyst, and technical assistant to advance safety improvements, leveraging the Roadmap framework to inform, incentivize, and implement statewide change.

  • Who and what is affected

    • Health care providers across Massachusetts (hospitals, outpatient facilities, ASCs, long-term care providers, maternal care services) receive technical assistance, safety resources, and learning opportunities.
    • Patients and families benefit from PFAC engagement, CARe processes, and peer support networks.
    • State agencies (e.g., DPH, MassHealth, EOHHS, PNQIN) collaborate on data collection, reporting, maternal health improvements, and interagency safety initiatives.
    • The public gains access to more timely data and improved transparency around safety events and hospital performance.

  • Procedural and timeline aspects

    • Foundational safety curriculum: First course to launch in 2026.
    • AAEM pilot: Funded in FY26; results to be published to inform statewide implementation and standards.
    • PFAC enhancements and reporting: Ongoing, with annual statewide PFAC reporting and local PFAC improvement efforts.
    • Long-term care and maternal health initiatives: Ongoing interagency development and pilot programs beginning in early 2026, with evaluation components built into learning collaboratives.
    • The report itself is submitted under the Betsy Lehman Center for Patient Safety per General Laws, serving as the Center’s 2025 annual report to the Legislature and the public.

Note: This summary reflects the contents and findings presented in the Betsy Lehman Center’s 2025 Annual Report as submitted under HD 6116.

Compiled from official sources — confirm details with the bill’s official record.

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