Family of woman who died after a medical error joins hospital's safety panel
Bob and Barb Malizzo, along with daughter Kristina Chavez and her son Adrian, visit their daughter Michelle Ballog's grave at Graceland Cemetery in Valparaiso, Ind. She died after a medical error was made during surgery. (Heather Charles/Chicago Tribune)
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."