The emergency department now gets most patients to a bed within 20 minutes and calls in extra doctors and nurses if patients are waiting too long, he said.
In another issue, employees who write the newsletter interviewed the wife of a patient who had muscle and kidney damage when a doctor overrode computer warnings about dangerous medication interactions. “It pretty much devastated my entire family,’’ the wife said in the newsletter. The hospital now requires the pharmacist and doctor to discuss side effects before prescribing these particular drugs.
The idea for Safety Matters came from Dr. Elizabeth Nabel, Brigham chief executive, and several other hospital leaders. She has said that one of her goals is to create a more open culture around medical errors, in which staff can report them and seek help without shame.
Last October, she led by example when she described to a hushed auditorium of doctors and nurses an error she made years ago at the University of Michigan.
She was repairing a patient’s aortic valve and punctured the left ventricle of the heart with a wire, causing significant bleeding and requiring the patient to undergo surgery, she told the audience.
“I felt very insecure and my confidence was shaken,’’ she said, noting that she was the only woman in the cardiac catheterization lab. “I can assure you there were a lot of men who didn’t want me to be there. This would only give fuel to their fire.’’
Nabel could talk only to her husband about the case. “Think about how much easier it would have been if I could have talked to my colleagues rather than living in fear I would get stabbed in the back because I made this mistake,” she said. She said she disclosed the error to her patient, who eventually recovered.
Kachalia said caregivers involved in the errors are allowed to review the newsletter before it is published. Only one has objected to having a case included, and the hospital agreed.
Janet Barnes, executive director of compliance, said she initially was hesitant about the project, in part becauseshe worried it would give lawyers ammunition for lawsuits. Staff in her office review the language in each issue to make sure it is factual and does not editorialize; for example; calling an event “horrible’’ or “terrible.’’
“There’s definitely a balance,’’ she said. “We want people to know we are working to improve. But you want them to come here and feel safe and not come in the door and worry.’’
Dr. Kathy Selvaggi, director of the Intensive Palliative Care Unit, was the doctor of the cancer patient whose transfer to Spaulding Rehabilitation Hospital went awry.
“When she had to come back, my heart sank,’’ Selvaggi said in an interview, describing her pain as “unbelievable.”
“We felt we let our patient down.’’
Selvaggi said doctors and nurses from the Brigham and Spaulding immediately met to analyze what went wrong and devise improvements.
One problem was that the patient’s transfer was delayed. A translator needed to provide the patient discharge instructions was late, so the patient did not arrive at Spaulding until 5 p.m.
By that time, key Brigham doctors had left work and could not be reached by the Spaulding caregivers, who were confused by the Brigham’s medication instructions. When they finally figured out the correct drugs, they realized the doses were so high they were outside Spaulding’s policy. So the patient was sent back.
The Brigham made several changes, described in last April’s newsletter. They included not sending patients with complex pain regimens to Spaulding after 4 p.m., and requiring doctors, not just nurses, to speak by phone to review instructions in complicated cases.
Erin McDonough, the Brigham’s senior vice president of communication and public affairs, said stories like this one have more impact than statistics. “That was really our goal,” said McDonough, who helped develop Safety Matters, “to make it memorable so that it would stick.’’