Making Our Hospital Safer


This picture is an MRI tech’s worst nightmare. This happened when a metal stretcher carrying a patient was inadvertently wheeled into an MRI room. The powerful magnet in the MRI began pulling the stretcher toward the machine. The patient was quickly and safely removed from the stretcher, but the stretcher, as you can see above, was pulled onto the MRI, causing significant and costly damage.

Was this reckless behavior or a mistake that anyone could make under similar circumstances?

At the Brigham, these are the types of questions that we seek to answer. In a Just Culture, staff are treated justly and fairly when they are involved in an error, whether or not it results in harm. It is critically important to patient safety that we have a culture where employees feel empowered and comfortable in speaking up about mistakes so that they can be fixed. We can only improve if we make it safe for employees to be open about mistakes. That includes not punishing them for “human error” – mistakes anyone could make.

We recently completed our third Patient Safety Culture Survey, which gives us insights into important issues like whether staff feel comfortable speaking up when something simply doesn’t feel right. We learned that people are hesitant to speak up. We started Safety Matters to be more transparent in admitting and discussing mistakes with the purpose of preventing the same mistakes in the future. We are committed to continuing this work to ensure that we have a Just Culture – that is what will make our patients safer.

In the event I described above with the MRI, we considered the circumstances through a Just Culture lens and concluded that the technologist’s mistake was one anyone could have made. He did not willingly violate any rules. He momentarily erred on the direction he was pushing the stretcher. We found that firing the employee wouldn’t prevent this same mistake from happening to someone else, but rather that we needed to improve the system to make this mistake less likely to occur. To meet that need, we equipped all MRI room entry areas with a simple safety barrier. We’re proud to say that the employee remains part of our team, and that we are a safer organization as a result of his input.

The Boston Globe wrote about this case, as well as MRI safety issues in general, in this article published April 8. In addition, the Betsy Lehman Center published this Q&A.