ospitals celebrate their safety records, but rarely discuss their mistakes. Yet it’s difficult, if not impossible, to improve safety without identifying and learning from errors. That’s why Brigham and Women’s Hospital has launched Safety Matters. This blog aims to describe mistakes made at the hospital along with steps the hospital is taking to prevent them in the future.
The current entries cover medication errors, delayed diagnoses, incorrect use of an intravenous line, and other problems that harmed, or could have harmed, a patient. Each article describes an error, how it came to light, and the steps taken to prevent it from happening again. When possible, it also includes comments from the patient who was on the receiving end of the error, and possibly his or her family members. The patient story is pivotal because it lets care providers understand how mistakes affect the lives of patients and their family members.
Take, for example, the story of a delayed cancer diagnosis in an 85-year-old woman who was being followed for a seemingly benign growth in one of her lungs. Her primary care physician asked her to have an X-ray to check the nodule. It showed suspicious growth, so the woman had a CT scan to better assess the growth.
The radiologist sent the CT results — which indicated probable lung cancer — to the primary care provider, but didn’t include a separate note warning of an abnormal finding, assuming that the primary care physician was aware of the CT result. But the primary care physician overlooked the CT report and didn’t act on it until noticing the report five months later during a follow-up visit with the patient. A new CT scan showed further progression of lung cancer. The primary care physician told the patient about the error and apologized. Her cancer was treated, but she passed away about a year later. Although the delay probably did not affect her outcome, it was important to us — and to the patient’s daughters — that we do everything in our power to prevent this from happening to someone else.
After the error came to light, the woman was invited to attend the Brigham’s Morbidity and Mortality Rounds to share her story. The event, her description of it, and the perspectives of the clinicians involved helped change how the hospital communicates clinically significant test results. “My mother would be happy to know if this makes a difference for somebody else,” said one of her daughters in a Safety Matters report.
We began Safety Matters in 2011. At the time, it was an internal communication available only to Brigham and Women’s employees via the hospital’s intranet. One goal is to make sure that everyone on the staff knows that the hospital is committed to being open and transparent about mistakes and learning from them. Another goal is to convey that reporting mistakes is not only encouraged, but is also the right thing to do.
Another element of some blog entries is the “Just Culture Corner.” It helps promote a culture in which hospital staff and patients feel safe and supported when speaking up about mistakes and risks.
Safety Matters went public in January 2016. We did this for several reasons:
The same errors that happen at the Brigham happen at other hospitals. But the Health Insurance Portability and Accountability Act (HIPAA) and legal issues can make it tough for a safety specialist like me to discuss the specifics of a case with a colleague at another hospital. Safety Matters meets HIPAA’s privacy standards because we get permission from the clinicians and patients involved in a case before we publicly discuss it.
The feedback we have received from individuals inside and outside the Brigham has been overwhelmingly positive. A number of other hospitals have reached out to ask about the steps needed to launch their own efforts to openly talk about mistakes and solutions. That could become an excellent forum through which we could all learn from each other.
We work hard to make sure that Brigham and Women’s Hospital provides the safest and highest-quality care possible. One way to underscore our commitment to that is to identify when we don’t meet that standard and show what we are doing to fix the problem. Safety Matters is an important way to do that.
Karen Fiumara, PharmD, is senior director of patient safety at Brigham and Women’s Hospital in Boston. She oversees Safety Matters.