From the minute she regained consciousness in the ICU, Kenney, who is married and has three children, wanted to know what went wrong. A nurse told her she’d probably had an allergic reaction to the anesthesia. But, says Kenney, “I knew intuitively that wasn’t true.” Even today, nobody knows precisely what happened, but the most likely explanation, says van Pelt, is that the needle inadvertently punctured a vein. Van Pelt hadn’t been clumsy or inattentive and neither he nor Kenney believes he made an error–but he had been at the helm. “I was responsible,” he says. “I had created a horrible adverse event with a standard procedure.”
The MO in hospital “risk management” has long been not to talk about adverse events, and Brigham was true to form, offering Kenney little information after she went home. “I felt abandoned by the hospital,” she says. But van Pelt himself could not suppress the trauma, and he took the unusual step of sending Kenney a letter of apology, in which he offered to talk. Six months later, the two had a heartfelt conversation and, for the first time, says van Pelt, “she found out what had actually happened.” And she offered her doctor forgiveness. “That was a very profound moment,” he says. “I felt like I had my life back.”
Since then, van Pelt and Kenney have teamed up to speak out about their experience and to open lines of communication between doctors, hospitals and patients. Both suffered emotionally, and both are now helping others. In 2002, Kenney launched Medically Induced Trauma Support Services, a nonprofit that provides support to anybody involved in an adverse event. Van Pelt talked to Brigham administrators about the need to acknowledge the impact errors can have on patients and staff. In July, the hospital launched the Peer Support Team Initiative, which connects doctors and nurses with their colleagues after adverse events, offering a safe environment for them to discuss what happened and seek emotional support.
Today, Brigham is a leader in patient safety–and in openness when things go wrong. “It’s a culture that says, yes, we have a problem, let’s shine a light on it and fix it rather than trying to cover it up,” says chief medical officer Dr. Andy Whittemore. Many changes were initially spurred by the IOM’s 1999 report. Among them: “Executive Walk-Rounds,” in which senior leaders visit frontline staff throughout the hospital and ask pointed questions: “What’s worried you lately? Have you felt you put a patient in harm’s way? Did you give a wrong dose?” Patient-safety officers then make lists of what needs to be fixed, and Whittemore insists that they get back to the person who reported the problem–whether it’s a delay in medication or a broken trolley–so they know they’ve been heard. “We’re not pointing fingers and we’re not interested in creating blame,” says Whittemore. The hospital also launched a computerized “incident reporting system” so problems can be documented and dealt with quickly and efficiently. And it spent $10 million creating a high-tech drug-dispensing system, complete with bar codes, which have slashed medication errors by 80 percent. Computers play an integral role, uploading critical info about the drug, the nurse and the patient, then giving a yes (a big green check) or a no (a big red X) before drugs are administered.
For Kenney and van Pelt, the new safety systems and culture of openness are heartening. The entire experience, says van Pelt, “has restored my humanity.” A much-needed ingredient in good care. –C.K.
