When Things Go Wrong, Admit Mistakes

Something went wrong a few years ago when Michelle Malizzo Ballog underwent surgery to replace a temporary stent in her liver at the University of Illinois Medical Center, Chicago, IL. Tim McDonald, MD, chief safety officer, tells me he remembers vividly the text he received from a nurse as Ballog stopped breathing: Come quick. Things going badly. Cardiac arrest.

The 39-year-old woman suffered cardiac arrest, lapsed into a coma and died several days later. Within hours, McDonald and other hospital officials, including the risk management officer, went over details of Ballog's hospital stay with her family.

McDonald had the sense that the father felt that "here we go, here's the whitewash." No, hospital officials told him, "We'll look into this." They did, McDonald says, and they found that hospital errors were to blame.

In the crucial minutes after Ballog's death, the hospital responded to stunned and questioning family members, and talked about things that went wrong. And the Malizzo family not only didn't sue the doctors, but her father, mother, and sister responded to McDonald's offer to join them on a safety review committee to prevent future medical errors.

What occurred did not turn tragedy into triumph, but served as a lesson – one step at a time – in which communication and cooperation helped detour the spiral of medical malpractice litigation.

UIMC's relationship with the Malizzos reflected "effective communication and appropriate resolution," McDonald says. "And appropriate resolution isn't always about money. That's the crux of our program."

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