, April 11, 2013

The patient, dying of metastatic cancer, had arrived at the hospital several weeks earlier in agony. But doctors at Brigham and Women's Hospital fashioned a medication regimen that at last eased her suffering, and on the day she was transferred to a rehabilitation hospital, they recalled seeing her smile. Hours later, the patient was back in the Brigham emergency department, and once again in excruciating pain. Delays in transferring her, a language barrier, and a communications breakdown between doctors meant she did not get her medications on time. Hospitals typically keep missteps like this quiet. But the Brigham openly recounted this mistake, and the improvements it led to, in a monthly online newsletter for its 16,000 employees, to encourage staff to talk openly about their mistakes and propose solutions.

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