The front page of the Boston Globe, April 10,2013 had an article by Liz Kowalczyk, “Airing Medical Mistakes.” http://bostonglobe.com/lifestyle/health-wellness/2013/04/09/brigham-and-women-publishes-stories-medical-errors-focus-staff-attention-solutions/heFVdgGnLc2O9QqL1eiMnN/story.html
Thank you Liz! This is a great article about the steps Brigham and Women’s Hospital in Boston has taken to come out of the closet about medical errors. The hospital started a staff only intranet newsletter called, Safety Matters, that addresses safety issues and describes medical errors. Names are anonymous but the actual event is real. I applaud the action of opening the door to understanding and transparency.
Medical mistakes take a toll on both the patient and medical staff. In the past, what most patients have experienced is a wall of silence and a quest for answers. Hospitals have in the past circled the wagons and rarely acknowledged publicly or to the patient any responsibility. Often, the only vehicle for a patient to discover what really happened was to file a lawsuit. To add insult to injury, hospitals had no qualms about sending patients bills after a medical error.
Patients, doctors and nurses all suffer when a medical mistake occurs. Doctors have had to live in silence with no where to turn. The article quotes the Chief Executive, Dr Elizabeth Nabel who stated “ one of her goals is to create a more open culture around errors, in which staff can report them and seek help without shame.” It is a bold move and one she takes personally. Dr Nabel last year, spoke to the medical staff and nurses about her own medical error many years ago and her struggle and shame. That takes courage and commitment to wanting real change around medical error reporting.
I believe the ability to be transparent is a direct result of the push by the patient safety movement, doctors speaking more openly about the issues and the new Maaschusetts law enacted in January 2012. The law allows doctors to apologize in the hospital for a medical mistake without fear of it being used in a lawsuit. This law has the potential to help both patient and doctor/nurse.
The article also spoke to policy changes that have occurred and are identified in the newsletter. That is remarkable because often an error occurs, the policy changes but the patient doesn’t know nor does much of the staff. It is important to openly explain the source and reason for a policy change. If a patient is injured due to a medical error, and a policy is changed because of the event, it can be very healing to know the error was not swept under the rug.
I had a client who had a surgery to remove an unknown object from the abdomen. No one knew how it got there (really, it was not from a previous surgery or ingested). My client had requested the object to be saved so the appropriate research could be done to find out how it had gotten into the abdomen wall. Two events occurred. Not all the object was removed nor was the object saved. Pathology threw away the object. My client doesn’t remember being told the object was not completely removed and ended up with an infection. He was also being billed.
I contacted risk management at the small hospital outside of Boston. I had written a letter explaining the object had been thrown away, not being informed the object was not completely removed and the receiving of bills. The response I received was confrontational and icy. I was surprised because my letter was not accusatory but asking for a dialogue. There were several phone calls and then silence for about 6 weeks.
During this time, the bills were dismissed and a policy was changed. My client or I were never contacted except that no more bills were sent. I only found out about the policy change because the risk management director mistakenly called my number and I asked what was happening. The policy for surgical removal of objects and the pathology department’s responsiblity was changed to include how to manage patient requests. New systems were put in place to ensure communications between departments. My question to the director was why wasn’t this commnicated.
The experience with this client is one I have often with hospitals and the risk management departments. Stone walling and non communication. That is why I am glad to read that Brigham is slowly opening the door to communication and acknowledging medical mistakes in a public forum. My suggestion is to now engage patients in the process. Use the consumer board that the law also states hospitals must have.