A Near Miss, An Important Reminder


While the COVID-19 pandemic continues to pose a significant global health threat, one recent near-miss patient safety event at Brigham and Women’s Hospital was a reminder of the need for continued focus on all public health issues, transparency and our culture of safety.

According to the U.S. Department of Health and Human Services, over 130 individuals die daily from opioid-related drug overdoses across the country, with over 10.8 million Americans misusing prescription opioids in 2018.1 In 2017, the opioid crisis was declared a public health emergency and efforts have been ongoing to, among other things, reduce the number of opioid prescriptions written overall, as well as reduce the number of opioid pills ordered per prescription. Research shows that electronic medical records, computer systems used to manage patients’ information while at the hospital, may make the issue of overprescribing opioids worse by setting automatic suggestions for the number of pills doctors should prescribe following certain procedures.2

In June of this year, one of our General Surgery residents experienced this problem when ordering opioids for several of his patients in our electronic medical record system. When prescribing oxycodone, an opioid typically prescribed for severe pain management, like that experienced after surgery, the pre-populated quantity in the electronic medical record prescription suggested he order 450 pills, far more pills than necessary, rather than the five he originally intended to prescribe. Concerned that this suggestion would result in his patients receiving many more pills than they needed, and aware this can put patients at an increased risk for addiction, overdose and even death,3 he alerted the Information Technology, Pharmacy, and Patient Safety teams so they could work to eliminate this automatic suggestion. The teams worked quickly, and within 10 hours, the issue was fixed not only at our organization, but across all hospital systems that use the same technology.

We are grateful that we can consider this event a “near miss” in which no patients received more opioid pills than they needed. We are fortunate to have a culture of transparency in which this physician was willing to speak up about the patient safety issue he identified.


1U.S. Department of Health and Human Services. What is the Opioid Epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html.

2Makary, MA., Overton, HN, Wang, P. Overprescribing is a Major Contributor to Opioid Crisis. BMJ. 2017 Oct 19. PMID: 29051174

3Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report.


The Healing Power of Connection


Now more than ever, we need to connect with those we love to stay healthy and well. Even as we self-quarantine, we have all made changes and found creative ways to communicate and connect with each other using video chats, phone calls, texts, or even hand-written notes. COVID-19 has created many challenges for hospitals and healthcare organizations globally, one of the most difficult being the struggle to connect patients with COVID-19 with their loved ones and to provide the emotional support they need while they are in the hospital.

Because COVID-19 is passed from one person to another, hospitals have been forced to put in place strict visitor policies. Recognizing how important physical and spiritual connection to loved ones is to a patient’s recovery and wellbeing, Brigham and Women’s Hospital has created several projects to bridge this connection and give patients the opportunity to connect with their loved ones even while they are in the hospital.

While family members are unable to be physically present in the hospital, one project created by Palliative Care doctors and first-year medical students, called “Get to Know Me,” has helped loved ones stay connected to patients and their caregivers during their hospital stay. Medical students interview family members by phone and make a small poster with photos and important facts about the patient as a person, aside from their illness, such as their pet’s name and their favorite television show. The poster is then hung outside the patient’s room for their care team to view and learn from.

Example “Get to Know Me” poster. Note: This poster and information is not of a real patient. 

In addition to the creation of these posters, several projects have been put in place so that patients can have “virtual” family and spiritual care visits while they are in the hospital. Through two different virtual family visit programs, patients in the Intensive Care Unit, with the assistance of their nurses, nurse practitioners, physician assistants or doctors, are able to have virtual visits via phone or video chart with their families or, if patients do not have their own devices, the hospital has created a program that provides patients with loaners so that they can easily stay connected with their loved ones throughout their hospital stay. These loaners are available from 7:00am-11:00pm daily.

To-date, over 600 virtual family visits have been facilitated by both virtual visit programs.

In addition to ensuring patients can stay connect with their family and loved ones, Spiritual Care Services, a Brigham service that aims to assess and serve the emotional and spiritual needs of patients and their families in moments of crisis and uncertainty, has created a program that allows patients to have spiritual care visits done entirely virtually. It is our belief that these programs contribute to the patient’s overall well-being, and that human and spiritual connection can positively affect a patient’s healing.

Our hope is that as the need for distancing continues, we will continue to expand these programs, as well as create others that address the constantly changing and unique needs of patients.




For this post, the Department of Quality and Safety asked one of our team members, Karthik Sivashanker, MD, MPH, CPPS, medical director for Quality, Safety, and Equity, to discuss Brigham Health’s focus on equity, how it can be misunderstood, and why it is a critical patient quality and safety issue.

The New Year is a common time for people to pause and consider what’s important to them and where they’d like to be in the future. At Brigham Health, we’re excited to renew our commitment to providing equitable high-quality care to all of our patients for 2020 and beyond. To understand why this is so important, we first need to understand what we mean by equity, and how that ties into the quality and safety of our patients’ care.

We can begin by asking what matters to you as our patient? For most of us, being treated with respect and dignity is high on that list. We might even say that we want to be treated “equally,” no matter our race, religion, language, gender, etc. But is equality really the goal or is it something else?

Here’s an example to help us think through this. Consider this picture of people waiting in line for the bathroom:

Have you seen long lines for the bathroom before? If so, is it usually for the men’s or the women’s bathroom? In general, most of us would say that women’s bathrooms tend to have the longer lines. Have you ever paused to wonder why that might be? Why would we design bathrooms that lead women to wait longer than men? The answer, of course, is that we didn’t. Or at least, we didn’t intentionally design bathrooms in this way. More likely than not, these bathrooms were designed with the assumption that what works for one group will also work for others, resulting in bathrooms that are designed similarly for both.

Are these bathroom designs working well for women? Clearly not. But what about for men?

Before answering, consider men who may be with women waiting in line. Don’t many of them end up waiting as well for their wife, sister, daughter, friend, etc. to finish? What about fathers with babies using bathroom that don’t have changing stations? Or fathers with young daughters who may have to bring their daughters into a bathroom full of men?

Clearly, many bathrooms don’t always work well for men either.

This is a simple example to illustrate a complex point. If we design bathrooms to be “equal,” they may not serve the needs of the diverse people using them. In fact, they may not serve the needs of anyone in the best possible way. We considered men and women, but we can ask the same questions for other groups like transgender people or the disabled. At the end of the day, equal doesn’t mean fair.

Instead, we should be aiming for equity. The goal with equity is to design a system that works well for everybody. This is easier said than done and gets even more complicated when you think about how these ideas apply to health care.

Consider the example of access to routine preventative cancer screenings, like mammograms for breast cancer. Many people don’t have the money, social support, or the other things that are needed to access such care. Although care is equally available to all groups, inequities exist that prevent certain groups from receiving the care they need.

Here at Brigham and Women’s Hospital, we feel strongly that every single patient should get the very best and safest care (i.e., equitable care). This does not mean treating every patient the same, because who we are matters. What works for one patient may not work for another. With this in mind, we are taking a new approach that considers equity at every step of the way, starting with patient safety and quality.

When a patient suffers an avoidable harm, we try to understand what happened. This means getting at the “root” of the problem using different tools. Instead of re-inventing the wheel when it comes to equity, the idea is to take the same “root cause” approach, and to add an equity lens. Sometimes, this is as simple as asking the question: “Was there an inequity that played a role in this patient not receiving safe and excellent care?”

An article (and Podcast) in the New England Journal of Medicine this month by Dr. Karthik Sivashanker highlights this approach and explains a new way of thinking about patient safety, quality, and equity that should improve the care for all our patients and families. You can learn more by reading the article here.



For this post, the Department of Quality and Safety asked Hojjat Salmasian, MD, MPH, PhD, Brigham Health medical director of Data Science and Analytics, to discuss an innovative project involving patient photographs that is helping keep our patients safer.

Innovations in patient safety do not have to be complicated. Sometimes, a solution to ensuring patients receive the right treatment is as simple as having their photograph taken and displayed in their electronic health record (EHR).

Nationally, medication errors are a significant patient safety risk and wrong-patient errors are an important root cause of medication errors. Wrong-patient order errors occur when a provider orders a medication, test or procedure for the incorrect patient. The consequences of wrong-patient orders can be significant, even resulting in death. At the Brigham, we have identified this as an important vulnerability and have begun to re-think how wrong-patient errors can be prevented.

Our hospital came up with a potential solution: If a patient’s headshot photo was included on the main screen of his or her EHR, would providers be less likely to confuse patients and make mistakes? This intervention is particularly appealing because it doesn’t interrupt the clinicians’ workflow, unlike electronic alerts or “pop-ups.”

The project team chose the Emergency Department (ED) as the first location to implement this new strategy for several reasons. The ED is one of the major points of entry for our patients, and therefore taking photos in the ED will ensure patients benefit from this safety plan throughout their hospital stay. Additionally, care teams in the ED frequently multitask, caring for multiple patients simultaneously– these factors contribute to the ED setting being a higher risk for placing an order for the wrong patient.

Beginning in 2017, when patients arrived at the ED, staff in Patient Access Services would introduce the initiative and explain the safety benefits of having a photo displayed in the EHR. If a patient agreed to participate, the registrar would take a photo using a handheld device and upload it into the EHR. When a provider opens the patient’s EHR, the patient’s photo would be visible within the EHR Header (Figure).

Data and photograph shown in this image are not of a real person.

Multiple leaders from our institution came together to make this project a successful reality. This includes Adam Landman, MD, MS, our chief information officer, who is also an emergency physician and Bonnie Blanchfield, ScD, assistant professor of Medicine, Harvard Medical School and Harvard TH Chan School of Public Health. Landman and Blanchfield also secured funding from CRICO (our liability insurance provider) to subsequently study the impact of the patient photos on patient safety.

A recent analysis of data from the initiative shows that when patient photos were available in the EHR, providers were at least 35% less likely to place an order for the wrong patient. Although wrong patient orders occur only in about 1 of every 1000 orders, at a hospital like Brigham and Women’s Hospital where providers place millions of orders every year, this 35% reduction has profound implications for improving patient safety within our hospital. We owe this success primarily to two groups: our patients, who partnered with us in this initiative, and our ED Patient Access staff, led by Kelley Joyce and Kaila Centeio.

Due to the enormous success of the program, the Brigham is excited to expand this program into all inpatient areas. We believe this project is an example of a simple, “low-tech,” and inexpensive solution of how thinking outside of the box can help improve patient safety, while ensuring our providers are able to focus on what they do best: providing the highest quality care to our patients.



For this post, we asked one of our Department of Quality and Safety medical directors, Mallika Mendu, MD, MBA, to discuss a mortality-review tool being utilized to drive improvements in medical errors that lead to unnecessary deaths.

Patients depend on hospitals to get the care they need. But sometimes, health care institutions fall short for many different reasons. Research estimates that each year, medical errors cause between 210,000-400,000 deaths nationwide.1 Every one of those deaths represent an opportunity to ask questions, learn from mistakes and improve systems going forward. At Brigham Health, we want to ensure that we learn from every error that contributes to death at our hospital.

Safety science experts have emphasized that the most crucial step towards reducing deaths due to medical errors is rapid identification of these errors and potential errors, or what we refer to as “near-misses.” This identification can be extremely challenging, particularly when a patient’s treatment is complex, involving multiple physicians, medications and procedures.

When we began the process of identifying errors or potential errors at Brigham, we realized the caregivers involved in the patient’s care at the time of death were often the most capable of identifying any potential issues that may have contributed to the patient’s death.

For these reasons, over seven years ago, Brigham Health developed and implemented a hospital-wide electronic tool used to capture real-time information about patient deaths from frontline providers. Using this tool, the team members involved in a patient’s care at the time of death almost immediately receive an email with questions around the circumstances of the patient’s death. The goal is to get providers’ perspective in real time, to understand if there was a medical error that contributed to the death, or if we, in any way, could have done things better. The information provided is then investigated confidentially by safety leadership, and steps are taken to address errors or implement improvements suggested. Using these investigations, our goal is to educate ourselves, and to learn from mistakes moving forward.

Since the implementation of this tool, there have been many positive changes made because of the information provided through these reviews. Some examples include improving our process of transferring patients from other hospitals, improving communication between various teams at the Brigham and enhancing end-of-life conversations led by physician trainees.

Brigham Health believes that we can continue to learn from every death that occurs in the hospital by using this tool and continuing to increase our efforts to promote transparency and feedback from staff. Reflecting on how we can provide better care on an ongoing basis is a key part of our mission.

You can read more about our inpatient mortality review system work in BMJ Quality and Safety, published here.


1Makary MA, Daniel M. Medical Error-The Third Leading Cause of Death in the US. BMJ. 2016 May 3;353:i2139.