Michelle Malizzo Ballog was nervous as hospital staff wheeled her into surgery to replace a temporary stent in her liver. In a procedure two weeks earlier, also at University of Illinois Medical Center at Chicago, she had awakened too early from the anesthesia, an unsettling experience.
But this time she didn't wake up.
Monitoring errors were made while she was under anesthesia, and Ballog, whose youngest daughter had turned 1 the day before, stopped breathing and suffered cardiac arrest on the operating room table. She lapsed into a coma and died nine days later at 39.
Her parents and sister had no idea at first that Ballog's death was caused by preventable medical errors, of which the monitoring problem was only the first. When they found out, they were livid. Bob Malizzo, Ballog's father, remembers angrily asking doctors: "How could this happen?"
To the family's astonishment, hospital officials did not duck their questions, cover up their mistakes or hide behind lawyers. Instead, they shared the tragic details.
As a result, the family made a surprising decision of their own: They chose not to sue and joined the hospital's safety review committee to help the medical center avoid making such errors in the future.
In their role as lay members of the committee, Malizzo, his wife, Barbara, and their daughter Kristina Chavez hear about medical errors and near-misses that occur at UIC and other hospitals, with the goal of helping to figure out how such mistakes can be avoided. They offer a unique perspective that often is lacking in meetings that typically focus on procedures, processes and practices.
Sitting in his living room in Hobart, Ind., next to a pillow memorializing his oldest daughter, Malizzo explained the family's thinking in joining the panel: "We might be able to save someone's life."
Patient safety experts praise the hospital for being transparent about the errors and said the case highlights the important role that patients and families can play in helping to fix a complex, intractable problem.
Patient advocates are pushing for greater involvement on the part of patients and families to reduce medical errors — everything from encouraging them to be assertive in raising concerns with health care professionals to enlisting more consumers to serve on hospital safety committees.
"We're really on the edge of something new, giving consumers more power over (important) information, and I think that's a really good thing," said Susan Hinck, policy consultant to the Missouri Health Advocacy Alliance.
The presence of patients on such panels, however, means disclosing inside information that many hospitals don't feel comfortable sharing.
No one knows exactly how many medical errors occur, but a landmark report in 1999 by the Institute of Medicine estimated that as many as 98,000 Americans die as a result of a medical mistake in any given year.
Newer studies published in the journal Health Affairs in April suggest that significant adverse events may occur in as many as 1 in 3 hospital admissions. The Centers for Disease Control and Prevention found that 100,000 people die annually from health care-acquired infection alone.
Patient safety was highlighted in the Chicago area earlier this year when James Tyree, president of Mesirow Financial and chairman of Sun-Times Media, died at University of Chicago Medical Center as a result of an error that health officials say should never happen.
Tyree, 53, served on the hospital's board of directors, proving that medical errors can happen to anyone.
After Ballog's death in 2008, officials at UIC Medical Center immediately shared their suspicions that fatal errors might have been made. They promised to investigate quickly and report back to her family. As soon as they realized they had done something wrong, they apologized and provided an explanation. And they speedily offered a financial settlement to provide for Ballog's two daughters, who were 1 and 7 at the time.
They also vowed never to repeat the errors.
"As head of patient safety in the hospital, I made it very clear that, at the end of the day, most of this rested on me," said Dr. Tim McDonald, the hospital's chief safety and risk officer for health affairs. "We, the institution, had let them down. Had we done the job we were supposed to do, this would not have happened."
Within 12 hours of Ballog's cardiac arrest, the medical center changed its procedures to require that an anesthesia specialist be present for the kind of procedure she was undergoing. Ballog's case was among those providing information used to help develop national guidelines on the use of a capnograph, a device used to monitor carbon dioxide concentrations in the blood of a sedated patient.
The medical center also has developed a program to prevent and respond to harm caused by medical errors, with an emphasis on being patient-centered and transparent. Under a federal grant, UIC helps other hospitals set up similar programs.
For their part, Malizzo, his wife or his daughter drive about an hour each way once a month to attend meetings of the hospital safety review committee.
"We don't want our daughter to die in vain," said Malizzo, a former mayor of Hobart who runs a medical staffing company.
In one meeting, Malizzo and his daughter were asked the best way to approach family members of a patient who died of a medical error after being transferred to another facility. They suggested that officials go to the family's home, where they would be more comfortable, instead of telling them in the hospital.
Malizzo said his trust in the medical center has been restored and he goes there regularly for treatment of a heart condition.
"We have seen at UIC that they are trying their very best to eliminate medical errors," he said. "I trust them to this day with my life."
Martin Hatlie, CEO of Project Patient Care, praised the medical center for being open about a sensitive issue and for taking the lead in finding solutions.
Errors are "a stubborn problem rooted in the way our health care system is organized and a (medical) culture that historically has been quiet about things that go wrong," said Hatlie, whose Chicago-based group seeks to prevent medical errors and improve health care quality.
Among the obstacles to reporting and reducing errors are health professionals' fear of litigation and loss of reputation, lack of training in how to communicate with families after harm occurs, worries about losing their jobs, and feelings of guilt, said Hatlie.
On the patient side, barriers include apprehension about angering health providers and feeling too intimidated to ask questions or raise concerns.
But that is exactly what patients need to do, said Hatlie, because speaking up can help correct minor problems before they worsen and cause serious harm.
To health professionals, he says: "Listen to patients when they are expressing concerns, because they probably know something you don't."
Knitasha Washington has seen the problem from both sides — as a health professional and as a daughter whose father died because of a medical error.
Patients have to be assertive and proactive, "asking, probing and doing your own research, whatever that might be," said Washington, president of the Chicago Midwest chapter of the National Association of Health Services Executives. "You can't take information as if it's golden; you have to ask questions."
The Malizzos say their work to help eliminate medical errors and promote transparency is a legacy to their daughter's generous and loving spirit. They plan on serving on the hospital's safety committee for the rest of their lives.
"You come to the realization that there's nothing you can do — it happened," Malizzo said. "They made a mistake. Where do we go from here?"
Tips for avoiding medical errors
Among steps you can take to minimize the chance of something going wrong:
•Ask questions, take notes and raise concerns (but do it respectfully).
•Seek second opinions if you need additional information.
•Repeat information back to your health provider to make sure you understood it correctly.
•Bring someone with you who can serve as an advocate while you are hospitalized or when you go to medical appointments.
•Learn the chain of command so you know where to direct your unresolved concerns.
•Ask health providers to wash their hands before examining you.
•Keep important details about your health and health care handy, including a list of medications you take.
•Find out which health providers will be taking care of you and their level of training.
•Consider using checklists available from consumer and patient safety groups.