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When Things Go Wrong, Admit Mistakes

Joe Cantlupe, for HealthLeaders Media, October 13, 2011

At least 40% of physician leaders surveyed in the HealthLeaders Media 2011 Intelligence Survey say fear of lawsuits is a major influence regarding their decisions to order tests or procedures. More than 60% of physicians age 55 and older have been sued at least once, according to the American Medical Association.

The AMA and dozens of other medical groups are pressing the Joint Congressional Committee on Deficit Reduction for a legislative package that includes a medical liability reform element. The physician groups want the committee to consider a "reasonable limit on non-economic damages" that would reduce the federal budget by $62.4 billion over the next 10 years, as the Congressional Budget Office calculates it.

While the political debate continues over medical liability, McDonald and the University of Illinois Medical Center show some improvements can be done, one step at a time, within hospital systems themselves.

After Ballog died, McDonald and his staff told the family uncomfortable details of what had happened. The Chicago Tribune reported that monitoring errors were made when she was placed under anesthesia and surgery, and that her parents were stunned that her death was caused by preventable errors that they didn't know about at first.

The hospital eased the family's concerns by being upfront. When the nurse wrote the text message, it was part of the hospital's "hotline" action plan for adverse events for which the hospital could be at fault.

"We maintained trust with (the family) and communicated throughout," McDonald says. Referring to the medical errors, "I would tell you, nobody behaved recklessly, and it was all mistakes and lapses that the entire team made which, truth be told, the institution could have been a little more on top of," he said.

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1 comments on "When Things Go Wrong, Admit Mistakes"


David Joyce MD MBA (10/13/2011 at 4:37 PM)
So let's hear about the bottom up continuous process improvement initiative that they have developed and how it has reduced errors. It is likely that there is none. Did having an anesthesia fix a problem, how prevalent was the problem, what was the root cause? They have a great committee to communicate when there is a problem but I would bet there isn't a single process improvement project led by those actually doing the work. Why, those who do the work do not have the business skills to improve.