Gordon Schiff, MD

Two decades ago, researchers from the Harvard Malpractice Study team published groundbreaking findings demonstrating that iatrogenic harm was epidemic (1),(2). These findings ultimately helped catapult two key Institute of Medicine panels and reports into national prominence and launch a national movement for patient safety (3),(4). That study demonstrated that not only was preventable harm in hospitalized patients much more common than previously suspected, but the spotlight on malpractice suits failed to illuminate the seven of every eight cases where preventable harm was occurring.  A newly funded study proposed to extend this work by broadening the focus from the inpatient setting (the focus of the original Harvard Malpractice Study) to outpatient practice where most health care is delivered and where the majority of malpractice claims now originate.

The project -- a collaboration between the Massachusetts Department of Public Health, the Massachusetts Medical Society, Brigham and Women’s Hospital, the Department of Public Health, the Institute for Healthcare Improvement (IHI), the Massachusetts Coalition for the Prevention of Medical Errors (Coalition), and the Massachusetts Medical Society -- has been launched to learn from and reduce outpatient malpractice risk.   Entitled PROMISES (Proactive Reduction in Outpatient Malpractice: Improving Safety Efficiency and Satisfaction), the demonstration project seeks to recruit and reimburse 16 general medical and family practice offices to work with (and receive free consultation from) the world’s leading improvement and efficiency experts to develop ultra-safe practices. 

This project has been funded with $2.9 million for three years by the Agency for Healthcare Research and Quality. PROMISES’ primary goal is to significantly improve and reduce problems in three areas that have potential for malpractice errors and suits: a) medication reconciliation; b) follow-up of test results and c) referral management.  In addition, a second and overarching aim seeks to improve communication — both among staff within office practices and, most importantly, between the office staff and patients -- during clinical encounters and to more effectively address patient concerns.  Growing evidence shows that problems in these three high volume processes (medication reconciliation, results follow-up and referrals) as well as breakdowns in patient communication, lead to frustration and anger, and underlie most malpractice claims.

This research project is designed to improve patient safety and reduce malpractice risk premiums in the Commonwealth.  During the third year of the project, we will evaluate and disseminate the lessons learned and share successful intervention tools and strategies across the Commonwealth with a broader audience of practices, practitioners, payers, and policy makers. Forums will be hosted by the MMS, the Coalition, Healthcare for All, as well as publications prepared by the research team based at Brigham and Women’s Hospital and the Harvard School of Public Health.

The project is currently recruiting the 16 demonstrations (and 16 control) practices, developing the improvement curriculum, and evaluation measurement tools. 

For more information contact Gordy Schiff at gschiff@partners.org.

Gordy Schiff, MD, is Clinical and Research Director, PROMISES Clinical and Research Center at Brigham and Women’s Hospital and Past Chair Medical Care Section APHA. 

   (1) Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324(6):370-376.

   (2) Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6):377-384.

   (3) Kohn L.T, Corrigan J.M, Donaldson M.S. To Err is Human. Washington: National Academies Press, 2000.