When Things Go Wrong, Admit Mistakes

Joe Cantlupe, for HealthLeaders Media , 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."

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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.




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