A story resonated deeply with me today was that of Melissa Malizzo, a young mother of two who died while under anesthesia for a liver shunt at the University of Illinois. The event was unquestionably a terrible tragedy, and errors in monitoring and staffing while under anesthesia undoubtedly contributed to her death. However, unlike many hospitals, University of Illinois did not confound the family with obtuse language and communicate only through a bevy of lawyers. Instead, Dr. Tim McDonald, one of our faculty members who was the hospital’s chief safety and risk officer for health affairs at the time, was honest and forthright with the family. The U of I had adopted the CANDOR model of communicating, which is used when unexpected events cause patients harm. The model focuses on communicating in a way that is timely, accurate, transparent and just. The hospital took ownership of the error and made it clear to the family that the death was unnecessary and they would do everything possible to ensure that it did not happen again.
Good and transparent communication is little solace in the face of a tragic and unnecessary death. An apology will never begin to amount to the magnitude of a loss. It is, of course, better to prevent a error than respond appropriately to one. But the U of I’s response felt just, it felt as though the organization took its covenant to care for patients seriously and took all the more seriously any failure to honor that covenant.
Today we discussed the concept of setting a course of ‘true north’ in our clinical practice. It is the idea of holding steady to our personal code of morality in the face of the significant challenges of medical practice. Everything about the way that the U of I responded to that event felt like it aligned with my own “true north”. The hospital and providers were transparent and honest with Melissa’s family. They focused on correcting the systemic factors that contributed to the death. They treated the family members as humans, rather than liabilities. Importantly, the U of I took ownership of the mistake and they apologized.
Be honest. Be clear. Evaluate the systemic factors that lead to an error – be they leadership, equipment, communication or infection control – and then work to fix those systemic issues rather than attributing blame to a particular provider. Do not further emotionally traumatize those who are grieving by erecting legal barriers and obfuscating the facts. It is a privilege, honor, and huge responsibility to care for patients. This responsibility also extends to taking ownership of our failings and extending the utmost empathy and due diligence to family members, following an error. Let the needs of patients, and their families, guide us to ‘true north’.