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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.

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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.

Focus on solutions

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.

Why we went public

Safety Matters went public in January 2016. We did this for several reasons:

  • It’s now more accessible to the entire staff, and can be read from home or a mobile device.
  • It demonstrates to patients, prospective patients, and other stakeholders that the hospital is committed to transparency and continuous improvement.
  • It can be a resource for other hospitals in the United States and around the world to provide safer patient care.

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.

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  • It is very encouraging to see a well revered hospital acknowledge they too are “human” and make mistakes. Its too bad that HIPAA limits what we are able to hear about.

  • Technology Kills Bacteria that Cause Hospital Infections and Reduces Infection Rates

    October 20, 2011

    BOSTON, MA—Results from a comprehensive multi-site clinical trial demonstrated that the use of antimicrobial copper surfaces in intensive care unit rooms reduced the amount of bacteria in the rooms by 97 percent and resulted in a 41 percent reduction in the hospital acquired infection rate. According to researchers, this study is one of the first to demonstrate the value of a passive infection control intervention, one that does not rely on staff or patients remembering to take action. The results will be presented on Friday, October 21 at the annual conference of the Infectious Diseases Society of America in Boston.

    Objects in hospital patient rooms are a potential breeding ground for bacteria that cause infections. According to Dr. Michael Schmidt, Vice Chairman of Microbiology and Immunology at the Medical University of South Carolina, and a researcher on this study, bacteria on ICU room surfaces are responsible for up to 80 percent of patient infections. The results of this study demonstrate that reducing the amount of bacteria in the patient’s environment significantly lowers the risk of infection.

    Hospital patients have a 1:20 chance of developing an infection, and of those who do become ill, 1:20 have chance of dying. The CDC estimates that in the U.S., hospital acquired infections kill 100,000 people and cost $45 billion annually.

    The study was funded by the U.S. Department of Defense and took place at Memorial Sloan Kettering Cancer Center in New York, the Medical University of South Carolina, and the Ralph H. Johnson VA Medical Center, both in Charleston, where traditional objects, such as bed rails, overbed tray tables, nurse call buttons and IV poles, were replaced with antimicrobial copper versions.

    Independent laboratory testing has demonstrated that when cleaned regularly, antimicrobial copper products kill greater than 99.9% of the following bacteria within two hours of exposure: MRSA, VRE, Staphylococcus aureus, Enterobacter aerogenes, Pseudomonas aeruginosa, and E. coli O157:H7. For a complete listing of approved EPA public health claims for antimicrobial copper, please visit http://www.antimicrobialcopper.com. Study results are to be submitted to the U.S. Environmental Protection Agency for review and approval. Because many factors contribute to the risk of infection, individual results may vary.

    *snip*

    Any word on this?

  • That real good platform for both health careers and patients /clients. It should be encouraged. It’s my hope that in future it will be incorporated in medical ethics. Further more congratulations Brigham and Women’s hospital, for that initiatives.

  • We wholeheartedly applaud the steps Brigham and Women’s Hospital is taking to advance patient safety. But, we must disagree with its statement that hospitals “rarely discuss their mistakes.” To the contrary, hospitals discuss their mistakes all the time. They just do so in top secret meetings behind closed doors. Specifically, hospitals conduct “Morbidity and Mortality” meetings (“M&Ms”), at which mistakes are discussed thoroughly and candidly.

    These meetings are helpful in terms of getting to the bottom of hospital errors. And no doubt getting to the bottom of hospital errors is important, as medical error is the third leading cause of death in the United States. But the findings of M&M conferences are kept secret. People injured by poor medical care are not given the results of such conferences, even if a lawsuit is filed. Hospitals argue that if M&M findings were communicated to the patient, the hospital (or its negligent doctors) would be sued. Therefore, they would just stop having M&M meetings, and errors would not be corrected. That argument is true, and it is wrong on many levels, including moral and ethical levels.

    Yes, if patients were told the truth of who screwed up and how, there might be a lawsuit. But is that really a good and moral reason not to tell the patient? If my son throws a baseball through the neighbor’s front picture window, he and I can discuss it. We can agree he won’t play ball that close to the window again. We can also agree to keep secret from the neighbor which neighborhood kid caused the damage. I can even justify keeping that secret by saying that the only reason my kid confessed to me was that I told him I wouldn’t tell the neighbor. But what kind of lesson is that? The right thing to do – the only right thing to do – is knock on the neighbor’s door, fess up, apologize, and take the consequences. If that means my kid has pay to fix the window, so be it. It’s called accountability, and everyone – even doctors and hospitals –should be accountable for their actions.

    Hospitals should not hide behind “M&M” or “peer review” privileges. They should get to the bottom of all medical errors, and they should tell patients what happened. Maybe the patient files a lawsuit, maybe not. Frankly, if they aren’t willing to do it, laws should be passed that require both an M&M conference for serious mistakes AND notification to the patient of the results of that conference. Anything else is just wrong.

    Kudos to Brigham &Women’s for taking a stand. It’s a great start, but more must be done in the name of patient safety.

  • http://www.healthbeatblog.com/2011/06/new-study-focuses-on-medical-errors-in-outpatient-settings-a-wake-up-call-for-doctors/

    ~There are 30 times as many outpatient visits as hospital discharges.
    ~Invasive and high-technology diagnostic and therapeutic procedures done in outpatient settings.
    ~Absence of risk-management programs in outpatient settings is concerning.
    ~Up to 96% of ambulatory surgical centers are for-profit centers.
    ~90% of ambulatory surgical centers have doctors as investors.

    The hundreds of thousands of people who die per year due to medical error are calculated from information gathered in hospitals.

    Where are the statistics for deaths and injuries in outpatient medical/surgical settings?

  • I don’t call them mistakes, I call them accidents because they happened unknowingly. They should be discussed in details to prevent further such similar accidents. They teach everybody lessons. Thats the essence.

  • Bravo!
    I have long been an advocate of full disclosure, and open forums.
    Before Tufts, I was at two institutions that bristled at the realization that even an MD ON STAFF saw the flaws, rather than embracing the power of the opportunity to remedy them!

  • Tom Walker, a former NYCPD Lieutenant, went to work at a NY hospital. In his Bronx Hospital: A Memoir he writes of the deaths of people by the hundreds everyday:

    “The Harvard Medical Practice Study examined 30,000 hospital records in 51 New York hospitals. They found
    that the rate of adverse events to be 3.7% with a death rate of 4.3%. This might appear to be an acceptable rate or error, but if one extrapolates this to the entire country, it’s the equivalent of having two commercial airplane crashes every day of the year—500 deaths a day or 180,000 deaths annually. On top of that, there are 1.8 million injuries a year due to hospital error. If a police officer mistakenly shoots one innocent civilian, the city is rightfully concerned and the cop must be able to justify his actions or end up in jail. Our hospitals are killing innocent victims at the rate of 500 a day, and with the rare exception, nobody is outraged. Hospitals fail to report their Sentinel Events for various reason: • The fear of malpractice suits; • Knowledge of the event will damage their image in the community; • The bureaucratic blame game that is played in our hospital systems; and • Accreditation concerns—survival is a strong motivator.”

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