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.
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.
We need systems that support our clinicians in delivering the safest, high-quality care. When our systems do not do this, we are at risk for errors. In this issue of Safety Matters, we reflect on a case where our electronic ordering system did not give our care providers specific information about a certain medication. The result? A patient received an overdose that required an immediate response from Poison Control and an extended stay at BWH. Fortunately, he recovered, and we put in place some changes that better support our clinicians in differentiating between specific formulations of medications.
The opioid crisis has become a public health emergency in our country; an overdose can happen anywhere at any time. When one visitor to BWH overdosed in a public bathroom, tragically, he was unable to be saved despite best efforts by BWH staff to revive him.
BWH is increasing the safety of all who enter our hospital by increasing the availability of and access to the lifesaving medication naloxone, which is used to treat an overdose in an emergency situation.
“Our goal is to help our patients not get into this predicament in the first place,” said emergency physician Scott Weiner, MD, MPH, who formed the Brigham Comprehensive Opioid Response and Education (B-CORE) program with colleagues across BWHC departments and disciplines earlier this year. “We are working hard to provide patients with the appropriate doses of opioid medications and improve the prescribing practice of our providers to help keep our patients safe and reduce the incidence of opioid misuse and abuse.”
Please read the story below to learn more about this tragic case, and what we are doing to prevent a similar event from occurring in the future. Read More
When a breakdown in communication among the surgical team occurred at the end of a procedure, the patient suffered a second-degree burn.
The Operating Room (OR) is a busy environment, where teams are carefully managing many priorities to ensure the best patient care. In this case, although the joint surgery went smoothly, a hot light came in prolonged contact with the patient, causing the burn. Patients who are under sedation or general anesthesia are especially vulnerable, and we must do everything possible to keep them safe.
The take-away from this story: When procedures are conducted by teams that do not frequently work together, the importance of clear communication and protocols is even greater. Read More