The patient, dying of metastatic cancer, had arrived at the hospital several weeks earlier in agony. But doctors at Brigham and Women’s Hospital fashioned a medication regimen that at last eased her suffering, and on the day she was transferred to a rehabilitation hospital, they recalled seeing her smile.
Hours later, the patient was back in the Brigham emergency department, and once again in excruciating pain. Delays in transferring her, a language barrier, and a communications breakdown between doctors meant she did not get her medications on time.
Hospitals typically keep missteps like this quiet. But the Brigham openly recounted this mistake, and the improvements it led to, in a monthly online newsletter for its 16,000 employees. Brigham leaders started the publication to encourage staff to talk openly about their mistakes and propose solutions, and help make sure errors are not repeated.
While many hospitals post information on their websites about patient infections and falls, they rarely provide details of medical errors or candidly discuss with their entire staff how medical mistakes harmed patients. Executives fear the public will find out, sparking lawsuits and scaring off patients.
This reluctance, patient safety advocates warn, may be hampering the push to reduce medical errors because there is not wide discussion of how mistakes happen and can be prevented.
“Open-faced transparency is really valuable to staff at an institution because it causes them to know themselves better,” said Paul O’Neill, a member of the Lucian Leape Institute at the National Patient Safety Foundation, a nonprofit research organization based in Boston. But few, if any, other hospitals are doing anything like what the Brigham does, he said: “Unfortunately, I would say it’s highly unusual.”
The Brigham doesn’t make the newsletters readily available to the public — but it doesn’t hide them either; it gave the Globe all issues. The Brigham began publishing “Safety Matters” online in January 2011 on its employee intranet and will start distributing paper copies in staff lounges, conference rooms, and other gathering spots later this spring — a move that some hospital administrators initially opposed because they worried about scaring patients.
Most issues tell a story of medical care gone awry through interviews with caregivers and often with patients, and describe the hospital’s response, such as adopting a better transfer process following the case of the cancer patient. Patients are not named, to protect their privacy. Caregivers also are anonymous because hospital leaders do not want to discourage them from reporting problems.
“Other institutions are putting data out there but we are pushing the envelope with our story-telling,’’ said Dr. Allen Kachalia, associate chief quality officer. “Many patients have just been surprised that we’ve been asking them their side of the story.’’
Linda Kenney, who was the subject of a medical error at the Brigham in the late 1990s and is a board member of the National Patient Safety Foundation, said the most common complaint she hears from caregivers when speaking at hospitals is that when they report an error, they never hear back about fixes. “I like the idea the Brigham is encouraging people to speak up,’’ she said.
Still, while openness about medical errors benefits patients who are harmed, by making it easier to provide them support and compensation, it is unclear whether transparency has lessened errors at the Brigham or nationally.
O’Neill, a former US treasury secretary, has urged President Obama to require Veterans Affairs hospitals to post online daily all infections, falls, and medication errors, and when caregivers are injured, during the previous 24 hours — a step he believes the Brigham and other hospitals should take, too. “If it’s in real time, it causes people inside to pay the highest level of attention to what is going on,’’ he said.
Dr. Joshua Kosowsky, vice chairman for clinical affairs in the Brigham emergency department, said the Safety Matters newsletter grabs staff attention in a way other approaches to transparency do not. One issue featured a woman who waited in the emergency room for several hours with abdominal pain, and then left for another hospital, where she got an appendectomy.
“For a lot of staff throughout the hospital, a number is just a statistic,’’ he said. But discussing “a pretty dramatic experience’’ has helped change the culture in the emergency department, where “it has long been considered okay for patients to wait.”Continued...