Most hospitals have embraced the idea of disclosing medical errors to the patient and family members, but Brigham and Women’s Hospital in Boston goes a step further by informing all staff about these incidents. The policy could provide information to be used against the hospital in litigation, the risk manager says, but educating staff and improving patient safety are worth the risk.
Brigham and Women’s spreads the word about medical errors and other safety issues through its Safety Matters monthly electronic newsletter, which is part of a campaign that includes other initiatives to improve patient safety. Part of the hospital’s commitment to safety includes telling the stories of its mistakes, what was learned from them, and the systems improvements that were undertaken as a result, says Senior Risk Manager Mary White, RN, MBA, CPHRM.
Telling patient safety stories through Safety Matters helps to support a culture in which people acknowledge mistakes, openly discuss them in a blame-free environment, and take steps to prevent similar errors in the future, White says.
“Our goal is transparency,” White says. “Greater transparency and discussion about patient safety events allows for communication across the hospital and promotes sharing and spreading of ideas for change.”
Recent issues of Safety Matters have addressed incidents in which a newborn was harmed by a tubing connection error, and one in which a patient’s radiologist did not send a critical abnormal notification for a CT scan suggesting lung cancer. Clinicians, patients, and family members are interviewed about the incident, and their comments are included in the story. The accounts often emphasize the emotional impact of the errors. (For more on the content of the newsletters, see the story in this issue.)
SHARING LESSONS LEARNED
The effort began in 2010 with the goal of sharing important lessons learned from errors in the hospital, explains Karen Fiumara, PharmD, director of Patient Safety at Brigham and Women’s. Prior to that, the lessons were discussed only in the particular unit or part of the campus where the error occurred, Fiumara says.
“We knew that the same mistake that occurred on one floor in a particular building could happen at another building, but we didn’t have a good way to share that information,” she says. “If something happens, we need a way to quickly and clearly disseminate the lessons learned. That’s the immediate fix while we’re correcting the problem in the system and making that problem less likely to occur again. Building awareness is the first step.”
The idea of openly discussing errors with all hospital staff members was discussed for almost a year before Brigham and Women’s leaders were confident that any risks were outweighed by the potential benefits. “There was a lot of internal discussion before we could launch our first issue. There were different perspectives, with my patient safety team feeling very strongly that this kind of transparency supports our core values,” Fiumara says. “We brought in the risk management team also and hospital leadership. Everyone had to buy in to this.”
Fiumara recalls that a key concern was whether the information could be used against the hospital in court, and everyone acknowledged that there was a risk of that happening. The risk manager was obliged to consider how public discussion of a mistake could lead to a malpractice lawsuit, but White says they concluded that the information could be disseminated.
“When you tell a story about errors that have occurred in the hospital and the lessons that we’ve learned as a result, there is an inherent risk in that, but one that we were willing to accept given the potential this program has to prevent similar missteps in the future,” White says.
There also was concern about how telling these stories publicly would affect the clinicians, patients, and family members involved. Knowing how much clinicians are affected when a mistake leads to patient harm, the Brigham and Women’s team worried that telling the whole staff about their errors would be traumatic for them. Ultimately, the team decided that they could not predict the impact on the involved clinicians.
POSTED ON THE INTERNET
The first issue was published in January 2011 and until October 2015, the Safety Matters newsletter was available only internally at Brigham and Women’s. Now it is available to the general public on the Internet.
“That speaks to our commitment to transparency, and we do hope that other hospitals can learn from our experiences,” Fiumara says.
The stories selected for the newsletter are almost always those in which a patient was harmed by the error, rather than near misses. Fiumara acknowledges the learning potential from near misses, but she says they don’t have the same emotional impact as an incident that harms someone. The stories in Safety Matters are intentionally chosen and written in such a way as to emphasize how people were affected by the error.
“When you have thousands of people on staff and you’re trying to get their attention, to get them to actually read this story, you’re going to have better results with a story that tugs at your heartstrings,” Fiumara says.
The willingness of the clinicians and patients to discuss the experience also factors into what stories are told. Physicians and staff members are encouraged to participate, but the hospital respects the wishes of patients or family members who are not comfortable talking about the error or being quoted.
LIABILITY CONSIDERED
White and her colleagues in risk management consider the potential for liability when a story is suggested for the newsletter, but most can be used without putting the hospital at too much risk, she says. Patient names are changed, and the stories do not identify Brigham and Women’s physicians or staff involved in the incidents.
“There are no formal rules about what stories can be told. In fact, our team is often the source of the stories that are ultimately written about in Safety Matters,” White says. “The risk management team is involved in the collective decision about which stories will be most impactful, and multiple considerations, including the perspective of clinicians, patients, and family members, are factored into that decision.”
Fears about how clinicians would respond to seeing their mistakes spread throughout the entire organization proved to be overblown, Fiumara says. The response from clinicians and the patients or family members involved in the incidents has been overwhelmingly positive, she says, partly because the newsletter follows the hospital’s just culture philosophy, and it focuses on improvements and not blaming people.
“When we first launched, the staff was initially surprised that we were openly talking about our errors,” Fiumara says. “Now it’s seen as part of our culture here that we talk about these things and try to learn from our mistakes.”
SOURCES
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Karen Fiumara, PharmD, Director of Patient Safety, Brigham and Women’s Hospital, Boston. Email: [email protected].
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Mary White, RN, MBA, CPHRM, Senior Risk Manager, Brigham and Women’s Hospital, Boston. Phone: (617) 264-5853. Email: [email protected].
