Why Brigham and Women's Hospital put medical errors in blog form

February 22, 2016 | Print  |

In a time when hospitals and health systems are making physician reviews and patient outcomes publicly accessible, Brigham and Women's Hospital is taking transparency one step further: Publishing a public blog about medical errors.

The Boston-based hospital describes some of its medical errors and near-misses online for all to see in its Safety Matters blog, which the hospital hopes educates its staff, as well as patients and healthcare professionals from outside BWH, to prevent future mistakes.

Safety Matters has been around since 2011 as a way to address medical errors with all staff members and glean any lessons learned, according to Karen Fiumara, PharmD, the hospital's director of patient safety. However, until recently, only hospital staff had access to monthly editions of Safety Matters in PDF form.

Safety Matters became open to the public in the middle of 2015 "in the spirit of full disclosure," Ms. Fiumara says.

The blog is now updated once a month and details a medical error or near-miss that occurred at BWH.

Choosing the story

When selecting stories to share, one of BWH and the Safety Matters blog team's prerequisites is that there are clear benefits to making the story public. Or, in Ms. Fiumara's words, it's worth sharing if "there's an opportunity through education to try to prevent a similar event from occurring."

The team also takes patient privacy into account, as they don't want a patient to be identifiable from the featured story. The only time a story would be totally off limits is if a patient or family didn't feel comfortable putting information out there.

Previous entries have covered a medication error caused by a breakdown in medication reconciliation, a delayed diagnosis of hyperthyroidism due to missing lab results, and a tubing misconnection error in an infant compounded by lack of communication with the family.

BWH's patient safety and public affairs team write the posts.

Each post includes a breakdown of what happened, what went wrong and how the hospital is working to make sure the same mistake doesn't happen again. Posts also include a "Just Culture Corner" segment. Just Culture is the term for BWH's safety culture framework, and the segment reviews the story through this lens by discussing if actions align with the Just Culture framework.

According to Christian Dankers, MD, medical director for quality and safety at BWH, Just Culture serves two purposes: to help identify and fix vulnerabilities in the system that could cause an error, and to respond to those vulnerabilities in a fair, collaborative way, making staff feel safe about coming forward about a potential problem.

The Just Culture Corner segment is included on the Safety Matters blog to reiterate the safety culture framework, Dr. Dankers says. "Hopefully we can help people understand the concepts and how they would be applied [to the situation]."

Getting over transparency obstacles

As with any attempt at transparency, support must come first from the top. Ms. Fiumara and her team first had to pitch C-suite members on the blog idea, who she says are "completely supportive of our transparency efforts."

Being completely public with medical errors has its risks, but "the potential educational opportunities and benefits of being transparent clearly outweighed concerns people may have had," Ms. Fiumara says. She also says that clinicians and staff members at Brigham and Women's have been supportive of the Safety Matters blog and eager to learn from mistakes made at the institution.

The blog's future

Safety Matters has only been public for a few months, but Ms. Fiumara has hopes for its future. She envisions it becoming a community where healthcare providers and experts use the comment section to share best practices on how to prevent errors.

"The end goal of all this is to make the care that we provide to patients safe," she says. "We really do owe it to our patients and families to be transparent with them and to be open and honest about what goes wrong and what we're doing to prevent errors in the future."

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