HL20: Bob Malizzo—Learning From a Nightmare

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Bob Malizzo.

This profile was published in the December, 2012 issue of HealthLeaders magazine.

 "We don't want this tragedy to go in vain. Something has to happen to prevent this from happening again."

Bob Malizzo expected that executives at University of Illinois Medical Center at Chicago would blame anyone but themselves for the death of his daughter Michelle during what was supposed to be routine bile duct surgery at the hospital.

Malizzo, a Hobart, Ind., businessman and a former mayor of the city, and his wife, Barbara, were angry, confused, saddened, and looking for answers when they met with Tim McDonald, MD, UIC Medical Center's chief safety and risk officer to find out what had gone so horribly wrong during the April 2008 surgery.

Instead of excuses McDonald accepted the blame and offered an apology.

"Going in, obviously we were very skeptical that we were going to get the truth, but then when we sat down and they shared the truth with us it kind of defused the anger," Malizzo says.

When the Malizzos met with McDonald a few days after the surgery, Michelle, a 39-year-old mother of two young children, was on life support. She would die a few days later. An internal investigation determined that clinicians supervising the operation to implant a bypass tube in a clogged bile duct failed to notice that Michelle had stopped breathing during the surgery. It was later determined that she had been over-anesthetized and that she had suffered massive brain injury from the subsequent loss of oxygen.

"You still have that anger in you but not like it would be if they came in and said, 'Oh, it's not our fault. We didn't do anything wrong,' " Malizzo says. "Obviously you wouldn't trust anything they said after that and your anger would increase if you thought they were lying to you. You never really get over it but you learn to accept what has happened and then you have to decide what you are going to do."

Instead of hiring a lawyer, filing a lawsuit, and looking for a massive payout after years of costly litigation, the Malizzos sought another way to honor their daughter's memory. "Our immediate response to them was, 'We don't want what happened to our daughter to happen to someone else. We don't want this tragedy to go in vain. Something has to happen to prevent this from happening again.' " Malizzo says.

About 11 months after Michelle's death and with McDonald's encouragement the Malizzos accepted an invitation to serve on the UIC Medical Center's patient safety committee.

"We meet once a month, an hour to 90 minutes. We talk about hospital errors not only at UIC but also errors at other hospitals or harm that was done to people at other hospitals," Malizzo says. "We check our policies and procedures at UIC and if we see they are deficient, we make the changes to prevent some kind of error from occurring. So we review not only potential errors that happen at UIC but errors at other hospitals as well."

Since Michelle's death, for example, Malizzo says anesthesiologists' professional associations have called for the use of capnograms for sedated and moderately sedated patients to monitor carbon dioxide levels. "If the patient should stop breathing an alarm will go off," Malizzo says. "So what that does is give us some satisfaction that obviously my daughter's death didn't go in vain and that some positives are coming out of this so that other people maybe don't have to experience what we have experienced."

The family has also accepted what Malizzo called a "very generous" out-of-court settlement from the hospital that provides for Michelle's husband and two young children, who were ages 1 and 7 at the time of her death. 

Malizzo says most hospitals are stuck in the mindset of denying their errors often on the advice of their attorneys. He believes that more hospitals would take a more conciliatory tone if they understood that many injured patients and their families want answers and accountability.

"The positive thing that is coming out of this for hospitals is they are starting to see financially that they are actually saving money by being transparent because you eliminate the middle man attorney," he says. "The hospital makes the mistake. They make people whole again financially and then they move on and learn from their mistake. At UIC, their insurance premiums dropped $10 million this year because of being transparent, because of sitting down and talking with people and saying, 'It is our fault and what do we need to do to make you whole again?' "

"Maybe if we had gone to court we could have gotten more money but that isn't going to bring my daughter back and we were going to have a five- or six-year fight on our hands and your anger is intensified," he says.

The Malizzos will never get over Michelle's death. "It is something that as a parent you live with every day. When you see your grandkids you automatically think about your daughter and the things you did with her and the grandkids. It never leaves."

But the family endures by learning from tragedy. "It's gotten to the point where I am a patient at UIC. I have a bad heart," he says. "I am on the patient safety board and we see how hard they are trying to eliminate errors."