OpenNotes: Building a More Transparent Health Care System

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Seinfeld fans might remember the episode where Elaine can’t find anyone to treat her rash because of something a doctor wrote in her chart. She spends the whole episode trying to figure out what was in the note.

Although it made for very entertaining television, I’m happy to say that if Elaine were a patient at the Brigham today, she would have instant access to the note with just a few clicks of the mouse. In the spirit of transparency and patient safety, patients can now read doctors’ notes in their electronic health record through a feature called OpenNotes.

This is an important step toward improving communication and empowering patients to be more involved in their care, which improves outcomes. The Brigham introduced OpenNotes in January, giving patients access to summaries written by their physicians.

OpenNotes gives patients the opportunity to validate the information their provider wrote and correct inaccuracies. If a note says the patient has a peanut allergy and they don’t, the patient can simply mark it as incorrect.

During the course of an appointment, a patient may be taking in a lot of information and can forget something the doctor said. OpenNotes includes the doctor’s recommendations so patients can review them after the appointment.

Patients may also choose to give access to their health care proxy or family members.

We are working on making OpenNotes available to inpatients too. Soon everyone will be on the same page!

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PS: If you haven’t seen the Seinfeld episode, here’s a quick video produced by OpenNotes featuring snippets of Elaine’s unsuccessful quest.

“The Scariest Moment of My Life”

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During an office visit, a patient with diabetes was switched to a highly concentrated dose of insulin. The Food and Drug Administration requires that a special U-500 syringe be used with this concentration. The physician placed an order in our electronic health record for the high-concentrated insulin and the U-500 syringes. He noted the need for the U-500 syringes on both orders. The physician then electronically sent the orders to the patient’s pharmacy and informed the patient that he would receive a special syringe.

When the patient filled his prescription, the pharmacy provided him with the correct concentration of insulin but – unbeknownst to the patient – gave him the wrong syringe. The syringe the patient received is meant to be used with a much lower concentration of insulin and measures dosing in a different way. Imagine filling a 12 oz. mug with espresso instead of coffee – it’s the same amount of liquid in the cup, but the espresso is much more potent. As a result of the error, the patient unintentionally injected himself with five times more insulin than intended.

The overdose could have been fatal, but the patient, who had been managing his diabetes for quite some time, was able to recover after eating foods high in sugar to normalize his blood sugar. He remembers, “It was the scariest moment of my life.”

Upon learning what happened, the prescribing physician called the pharmacy to discuss what went wrong. He also found an alternative option: a high dose of insulin prescribed with a pen. The correct concentration of insulin is already inside the pen, so the opportunity for error is minimized.

At the Brigham, we are recommending changing our electronic ordering system to direct providers to the pen when they are placing an order for high-dose insulin.

In addition, I’ve shared this key learning with safety leaders at the pharmacy where this occurred, other pharmacies, and the Institute for Safety Medication Practices, a medication error group, which sends national alerts and identifies patient safety trends, with the aim of reducing the potential for harm to patients across the country.

As part of our commitment to transparency, we will continue to share stories about errors at Brigham Health and what we’ve done to prevent similar errors from happening again.

Have you experienced a medical error?  We’d like to hear from you.

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The Most Difficult Conversations in Health Care

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Health care providers choose medicine because we want to help people get better, but sometimes, we make them worse. Complications and injuries happen as a result of the disease or a natural consequence of treatment, and occasionally, as a result of a medical error. As providers, realizing that we’ve made a mistake that has caused harm to our patient and their loved ones is devastating.

We know that to preserve trust, we must have open, honest, timely conversations with patients and their families about what happened, but those conversations can be incredibly hard, because care providers, after all, are only human.

At Brigham Health, we have a long-standing commitment to transparency and have supported staff in having these difficult conversations. We still face challenges, but remain dedicated to taking steps to proactively bridge the gap of trust that may occur after a medical error, which is why we have joined the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI). The alliance consists of patient advocacy groups, teaching hospitals, medical liability insurers and statewide provider organizations committed to providing transparent communication, sincere apologies and fair resolution in cases of medical harm resulting from care that is not up to standards.

Communicating openly with patients about mistakes, apologizing and coming to a resolution is the right thing to do, and we are committed to doing it, even when it is difficult.

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Making Our Hospital Safer

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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.

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Expanding Our Horizons

Almost all of us, at some point, will depend on a hospital or health care facility for our own care or for the care of a loved one. And when we do, we want to know that the clinical staff are doing everything possible to provide us with the best care. This includes keeping us safe from harm. Without the assurance of safety, an institution’s clinical breakthroughs or scientific research discoveries, as well as its reputation, mean very little to patients.

When we launched Safety Matters six years ago, our focus was on communicating with our employees.  We sought to create more openness by sharing stories of errors that harmed or could have harmed a patient to educate staff and raise awareness with the aim of preventing errors from happening again. We’ve interviewed hundreds of clinicians, described in detail dozens of errors and, in response, made numerous changes in our systems and processes to enhance safety.

We remain fiercely committed to delivering the safest possible care and to developing a hospital culture where staff are comfortable speaking up about safety concerns. We also want to be fully transparent as we seek to engage patients in our efforts and educate them about quality and safety. To that end, we are repurposing this blog. Our goal is to share what we have learned with a broader audience – including patients and the general public, as well as our staff and clinicians everywhere.

We will discuss a broad range of issues in patient safety and health care quality, as well as what we are doing at Brigham Health to make care safer, including new programs and innovations. We will talk about matters such as the benefits and drawbacks of electronic health records, the importance of safety culture and what hospital and physician quality metrics mean, among many other issues.

We will also post stories about errors that occur at the Brigham and remain steadfast in our commitment to transparency, learning from our mistakes and ensuring staff are comfortable discussing errors.

We welcome your questions, ideas and suggestions for future topics. We encourage everyone to post comments and engage with us in a dialogue about making health care safer for everyone.