Revealing
Medical Errors Helps Chicago Hospitals Build a
Safer Health System
By Carolyn M.
Clancy, M.D.
July 10, 2012
A preventable
medical error happened when Michelle Malizzo
Ballog had surgery in 2008. Worse, it was
followed by tragedy -- her death at age 39.
When her family
tried to find out what happened, officials at
the University of Illinois Hospital in Chicago
didn’t dodge questions or have the family talk
to the hospital’s lawyers, according to the
Chicago Tribune
 .
Instead, the
officials looked into their hunch that a fatal
error occurred during Ms. Ballog’s surgery. When
they confirmed that information, they met with
the family and apologized. The hospital system
also provided a financial settlement for Ms.
Ballog’s two young children.
But the hospital
did more. The hospital changed its process for
giving anesthesia so the same error wouldn’t
happen again.
This process,
called "Seven
Pillars
,"
was adopted by the Chicago hospital system in
2006. Today, it is getting attention from
hospitals in other States. (A similar program at
the
University of Michigan has cut costs per
claim in half since 2001.)
The process is
based on openness about medical errors or
near-misses so health care providers can fix and
prevent them.
Seven Pillars
consists of these steps:
-
Report incidents
that could harm patients.
-
Investigate
those cases and fix problems before an error
happens.
-
Communicate when
an error occurs, even if no harm was done.
-
Apologize and
"make it right" by waiving hospital and
doctors’ fees.
-
Fix gaps in the
system that can cause things to go wrong.
-
Track data from
patient safety reports and see if changes
make things safer.
-
Educate and
train staff how to make care safer.
How well has the
Seven Pillars process worked?
Only 2 years
after it started, the process led to more than
100 investigations and nearly 200 specific
improvements. It was also the basis for 20 full
disclosures of inappropriate care that caused
patient harm.
Even though Seven
Pillars works at the University of Illinois, can
it help in other places?
To find out, the
Agency for Healthcare Research and Quality (AHRQ)
is funding a
3-year project in 10 Chicago-area
hospitals. The entire process is now being
tested at five hospitals; the other five will
report data only and compare their results to
the hospitals using Seven Pillars.
Early indicators
are positive. Hospital staff are reporting
patient safety incidents, and talking to
patients when near-misses or errors take place.
In cases where inappropriate care has taken
place, patients aren’t stuck paying fees.
The final results
of this project are still a year away. But AHRQ
is excited about the early results.
And others have
noticed. The State of Maryland, the Wyoming
Medical Society, and a group of western States
are figuring out how to use many elements of the
Seven Pillars process. In Washington, DC, the
program will begin at MedStar Health in October
2012.
The Seven Pillars
process works because it spells out and follows
steps that we know make a lasting difference in
building a safer health system. Reporting,
communicating, creating a culture of learning,
and other improvements move us closer to
identifying and fixing patient safety gaps,
rather than simply assigning blame.
These changes for
patients and clinicians will be watched
carefully around the country. My hope is that
changes like these will build lasting
improvements in the safety of our health system.
I’m Dr. Carolyn
Clancy, and that’s my advice on how to navigate
the health care system.
Resources
Agency
for Healthcare Research and Quality
AHRQ Innovations Exchange. Full Disclosure
of Medical Errors Reduces Malpractice Claims and
Claim Costs for Health System
http://www.innovations.ahrq.gov/content.aspx?id=2673
Medical
Liability Reform and Patient Safety Initiative
Progress Report
http://www.ahrq.gov/qual/liability/medliabrep.htm
McDonald TB,
Helmchen LA, Smith KM at al. Responding to
patient safety incidents: the "seven pillars."
BMJ Quality & Safety. Published online
March 1, 2010.
http://qualitysafety.bmj.com/content/early/2010/02/26/qshc.2008.031633
Shelton DL.
Family of woman who died after medical error
joins hospital’s safety panel.
Chicago Tribune, October 7, 2011.
http://articles.chicagotribune.com/2011-10-07/health/ct-met-medical-errors-20111007_1_medical-errors-safety-panel-patient-advocates
Current as of July 2012
Internet Citation:
Revealing Medical Errors Helps Chicago
Hospitals Build a Safer Health System.
Navigating the Health Care System: Advice
Columns from Dr. Carolyn Clancy, July 10, 2012.
Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/consumer/cc/cc071012.htm
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