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
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
Seven Pillars consists of these steps:
- Report incidents that could harm
- 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
How well has the Seven Pillars process
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
I'm Dr. Carolyn Clancy, and that's my
advice on how to navigate the health care system.
Agency for Healthcare Research and Quality
AHRQ Innovations Exchange. Full
Disclosure of Medical Errors Reduces Malpractice Claims and Claim Costs for
Medical Liability Reform and Patient
Safety Initiative Progress Report
McDonald TB, Helmchen LA, Smith KM at
al. Responding to patient safety incidents: the "seven pillars."
& Safety. Published online March 1, 2010.
Shelton DL. Family of woman who died
after medical error joins hospital's safety panel.
October 7, 2011.
Current as of July 2012
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