By Tim McDonald, MD, JD
A miraculous moment took place at 4 pm on the evening of April 25, 2012.
In the picture above, I am holding a watch in my right hand while standing next to Barb Malizzo at a recent CANDOR Event in Dana Point, CA. Barb was one three patient and family speakers who brought the patient voice into the room for the health system that had commissioned us to teach them the value of open, honest communication in healthcare. The watch is a symbol of the power that results from that open, honest, and effective communication with patients and families following patient harm.
Exactly four years earlier, on April 25, 2008 Michelle Malizzo-Ballog died in the Intensive Care Unit at the University of Illinois, where I worked as the Chief Safety and Risk Officer for Health Affairs with my friend and colleague, Dr. Dave Mayer. Michelle died as a result of a multitude of medical mistakes that resulted in our failure to rescue her. She suffered a respiratory and then cardiac arrest brought on sedative medications. Michelle died after several days of heroic measures in the ICU had failed to restore any neurologic function.
At the time of her death, we discovered the multitude of mistakes that occurred, and openly and honestly shared them with Michelle’s family. I found myself in the critical, yet important position of conveying all we knew, including the errors, to the family, and particularly to Barb and Bob Malizzo, Michelle’s parents. Their sadness and anger were palpable, yet their desire to maintain contact was clear and obvious. They did not want to be abandoned and, instead, remained open to an ongoing dialogue as we all struggled to make sense of this horrific catastrophe that changed so many lives forever. We promised to stay with them and not to abandon them.
We periodically stayed in contact by phone, and we eventually met in person for lunch in the spring of 2009, one year after Michelle had passed. At that time, we invited Bob and Barb and their youngest daughter, Krissy, to join the Medical Staff Review Board at the University of Illinois. This committee was charged with the review and development of solutions for serious safety events at the Hospital. Michelle’s family agreed to this appointment and joined as the “conscience of the community” – thereby meeting our ongoing promise to stay with them while they helped make sure what happened to Michelle did not happen to other people.
On April 25, 2012 – on the four year anniversary of Michelle’s death, Bob and Barb came to the Medical Staff Review Board meeting with 3 small packages – they handed one to me, one to our Director of Safety and Risk Management, Nikki Centomani, and one to Bonnie, the nurse who had so kindheartedly and tenderly care for Michelle in the ICU.
Bob and Barb explained that these presents had been given to us for the honesty, compassion, and empathy we had provided them from the time of Michelle’s initial cardiorespiratory arrest, up until this moment in 2012, four years later.
When we each opened our own package, we found, to our immense surprise, beautiful Movado watches with “Michelle Malizzo Ballog 4-25-08” inscribed on the back. At that moment I tearfully promised the Malizzos I would wear the watch at all patient safety presentations and workshops going forward – as a symbol of the trust and the love we have for each other – while never forgetting Michelle. This was a miraculous, powerfully healing moment for our care giving team, and I hope, for Barb and Bob as well.
Today, now more than 9 years after Michelle’s death I did a presentation about CANDOR at Connecticut Children’s Medical Center. I wore the watch. I remembered Michelle…