Revealing Medical Errors Helps Chicago Hospitals Build a Safer Health System

Agency for Healthcare and Quality (AHRQ)
by Carolyn M. Clancy, MD

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
www.innovations.ahrq.gov/content.aspx?id=2673

Medical Liability Reform and Patient Safety Initiative Progress Report 
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. 
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.
articles.chicagotribune.com/2011-10-07/health/ct-met-medical-errors-20111007_1_medical-errors-safety-panel-patient-advocates 

Current as of July 2012