Chicagoland Patient Safety Summit: Focus on Transparency

October 13, 2011    |   By: Calevir

Kimberly O’Brien shares a recent experience: The 2011 Chicagoland Patient Safety Summit kicked off on September 15th with a heartbreaking story from an Indiana family who recently lost Michelle – their beloved daughter, sister, wife and mother – to a medical error at a Chicago-based hospital. There wasn’t a dry eye in the room of over 150 providers and other patient safety advocates as Michelle’s family recounted the painful details of the days and hours leading up to Michelle’s premature and preventable death.

While listening to Michelle’s story unfold, my heart grew heavy . . . not only due to the sadness of two young children losing their mother and a mother losing her firstborn daughter, but also due to the enormity of the work that still lies ahead in the field of patient safety. After all, despite of all that has been accomplished in the past decade, the sobering fact remains that Michelle’s story, or some version of it, happens hundreds of times each and every day in the United States.

As I continued to listen, I learned that there was something different about Michelle’s story. That something different was the way that the hospital, University of Illinois – Chicago (UIC), handled the tragedy. Instead of following the common path of distancing itself from the patient/family and waiting for a civil lawsuit to ensue, the physicians and leaders at UIC did just the opposite. They reached out to Michelle’s family, admitting the hospital’s responsibility for series of mistakes that very likely led to Michelle’s death.

UIC physicians and staff apologized to the family, they mourned with the family, they compensated Michelle’s spouse and children, they attended Michelle’s funeral hundreds of miles away, and most amazingly to me, they invited Michelle’s family into a permanent seat on the UIC patient safety council. For over two years, Michelle’s family has been actively participating on this council, contributing to the analysis of, and solutions for, near-misses and adverse events occurring at the very hospital that took their loved one’s life. Today, rather than holding resentment towards UIC, the family is, in turn, very supportive of the hospital, especially in its efforts to improve quality and safety. Michelle’s father stated that UIC is taking care of his heart condition, that he trusts UIC, and that he wouldn’t go to any other hospital for treatment of his condition. I find this just amazing!

One of the safety leaders at UIC that responded to Michelle and her family is Dr. Timothy McDonald, Chief Safety and Risk Officer for Health Affairs for UIC. Partially as a result of Michelle’s story, Dr. McDonald has developed a structured program for disclosing adverse events to patients and families, called “The Seven Pillars” . If you are interested in learning about The Seven Pillars model and you will be attending the MHA conference in November, Dr. McDonald will be presenting at the 2011 MHA Convention on Thursday, November 10th.

There were many other wonderful speakers and presentations at the Chicagoland Summit, ranging from a discussion about the benefits of working with Patient Safety Organizations from Dr. Peter Angood, to an update of the Leapfrog Group from Leah Binder. However, I found Michelle’s story, and the amazing work that followed, to be the most profound. Yes, there is a lot of work ahead for all of us, but undoubtedly, progress is happening. Let us all keep our eyes fixed on patients, share our learnings with each other, and continue to stay the course. Full steam ahead!

To read more about Michelle’s story click here.

To read more about a Chicago journalist shedding positive light on hospital’s working to reduce medical errors, click here.


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