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When Things Go Wrong, Admit Mistakes
As hospital officials evaluated the mistakes, the focus became being "part of the solution, instead of part of the problem," McDonald explained.
In the hours immediately following Ballog's death, UIMC made clinical changes to require an anesthesia specialist be present for procedures such as hers. McDonald says that it is difficult in a litigious climate for doctors and hospitals to embrace new systems and acknowledge that things went wrong.
"We know that liability and tort issues are up front, and you need to embrace those and understand those and move forward, where you are telling the legal system, 'we don't need no stinkin' legal system to tell us when we've not done something right,'" McDonald says. "When we know we haven't done the right thing it is incumbent upon us to fix it and be honest about it and let's cut the baloney. At the end of the day those who should worry about assets are those who behaved recklessly."
As members of the UIMC's patient safety review committee, Michelle Malizzo Ballog's father, mother, and sister drive for an hour and a half to attend meetings. They have been contributing members of the panel, McDonald says. Michelle's dad Bob Malizzo "will say things in a very respectful way like, 'wait a minute, weren't we talking about this problem a year ago, and didn't you say you would fix it?' McDonald says."It's awesome."
About one year after his daughter's death, McDonald walked in the hospital and was surprised to see Bob Mallog hooked up to a machine for a cardiac procedure.
"He told me, 'this is the place where my heart was broken,'" McDonald recalls, "'and I'mtrusting you to fix my heart.'"
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Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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Comments are moderated. Please be patient.
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.