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When Things Go Wrong, Admit Mistakes

 |  By jcantlupe@healthleadersmedia.com  
   October 13, 2011

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."

Indeed, UIMC's communication style that was on display with the Malizzos was formed in its patient safety program that allows nurses, physicians, and administrative staff to move quickly to report, review, and effect change following patient safety errors, McDonald says.

Since 2006, the hospital has established a protocol known as the Seven Pillars: Crossing the Patient Safety Medical Liability Chasm.

Last year, UIMC received a $3 million federal grant for the program as a demonstration project.  The program objectives, as outlined by McDonald, are to "improve patient safety and mitigate medical liability risk through improved communication with patients and family, disclosure and early (monetary) offer when patients suffer preventable harm, and learning from mistakes to prevent future harms."

When UIMC began reporting on unsafe conditions, and harmful events, staff reported about 1,500 occurrences the first year – a number that seemed "highly" inaccurate, McDonald says. However, staff "spread the word that leadership was behind this" reporting initiative. Now, there are about 8,000 such events reported annually, McDonald says.

"To some extent, we know everybody's worried about getting sued," he said. "But if you take a principled approach to harm, you can avoid a whole lot of lawsuits, and come to appropriate non-adversarial resolutions. In a whole lot of our cases, we've avoided protracted litigation that brings docs in and everything else."

McDonald says UIMC "embraces the concept of collective accountability" when appropriate and "reaches out to the family for quicker resolution before they decide to go to trial."

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.

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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