As medical centers and health systems increasingly look for ways to combat errors and be more receptive to patient concerns, one hospital has taken a bold move – publishing a public blog describing its medical errors and close calls. The hospital, Brigham and Women’s Hospital in Boston, has had an internal newsletter since 2011, which provides information on medical errors that occurred at the hospital. Until recently, the newsletter – called Safety Matters – was only distributed in PDF form to hospital staff. In mid-2015, however, the hospital, in the spirit of full disclosure, decided to release Safety Matters as an online blog. “Our goal is simple:” states the website. “By telling these stories, we hope to show everyone that, while improving care is not easy, we are absolutely committed to transparency, to learning from our mistakes and to continuous improvement.”
Recent cases presented in the blog include a medication reconciliation error that led to a patient getting a dose of medication that was 16 times higher than it should have been, and a delay in diagnosis caused by lab test results not being returned. The cases describe what happened, what went wrong, what system improvements the hospital is making to prevent this sort of error from occurring again, and what the patient’s role can be. Each story is accompanied by a Just Culture section. According to the Safety Matters site, Just Culture “refers to a system of shared accountability in which organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner. Employees are accountable for the quality of their choices and for reporting errors and system vulnerabilities.” The hospital’s goal is to make staff feel safe and supported in speaking up about mistakes.