A Patient Died On His Watch, Now He’s Shattering The Wall Of Silence Within The Healthcare System

Dr. Tim McDonald

Inland Empire Health Plan (IEHP)

Dr. Tim McDonald says his commitment to patient safety was born out of very close family members being harmed by medical errors and out of a harrowing experience he had with a patient. “A woman came to our medical facility, where I was working as the Chief Patient Safety Officer, for a surgical procedure; and, a pre-op blood test indicated a potential cancer diagnosis,” he says. But due to communication breakdowns, the surgery proceeded, and she died six weeks later due to a treatable leukemia. “We made a ton of mistakes. And clearly contributed to her death,” he says.

After the patient died, Dr. McDonald met with the CEO and other hospital leaders and said he wanted to be honest with this woman’s family. “And they said, ‘stay silent’. Of course, we then got sued. And instead of owning it, we defended it for four years, spending hundreds of thousands of dollars defending the indefensible until we settled for millions on the courtroom steps.”

Dr. Tim McDonald, TEDxSanDiego

MELISSA JACOBS

As he shares in his TEDx talk Dr. McDonald says the “wall of silence” is driven by shame and a fear of litigation and prevents healthcare professionals from admitting errors and learning from them. “This lack of transparency not only harms patients but also contributes to the burnout, emotional exhaustion, and moral injury experienced by healthcare providers,” he says.

Changing Course

Dr. McDonald felt compelled to address the glaring issues in patient safety after becoming a licensed attorney back in 1997. His dual expertise in medicine and law uniquely positioned him to bridge the gap between these two fields. Since 2020, Dr. McDonald has served as Chief Patient Safety and Risk Officer at RLDatix, a global enterprise software company offering software and services tailored to healthcare organizations. “We’re here to support hospitals and other providers with patient safety, risk mitigation, regulatory compliance, and workforce management resources.”

His work led to the creation of the “Seven Pillars” approach to preventing and responding to harm, which gained recognition and support from Senator and then-President Barack Obama and his administration. “The success of this initiative encouraged further developments, including the AHRQ-funded Communication and Optimal Resolution Toolkit (CANDOR), which was released in 2016.” Dr. McDonald’s work continues with implementing CANDOR and promoting the BETA Healthcare Group’s BETA-HEART approach (Healing, Empathy, Accountability, Resolution, and Trust) across the healthcare sector.

Three Key Principles for Patient Safety

HQI Panel. Seated L to R – Deanna Tarnow, Steve Burrows, Leilani Schweitzer, Dr. Tim McDonald.

Shannon Carroll

When it comes to improving patient safety, Dr. McDonald shared what he believes are essential components:

Open and Honest Communication: When unexpected harm occurs, healthcare professionals must commit to rapid, open and honest communication with patients and their families.
Apology and Learning: In cases of inappropriate care, healthcare providers should offer a sincere apology, and reconciliation and then focus on learning from these tragedies.
Support and Empathy: A culture of empathy and support is crucial for both patients and healthcare providers affected by adverse events. This approach aims to prevent moral injury and emotional exhaustion among healthcare professionals.

A Call to Action

Simply put, Dr. McDonald says medical errors happen way too often. “The New England Journal of Medicine, published in January of this year, showed one in four patients suffers a harm event and 10% of all patients suffer preventable harm. It costs billions and billions of dollars. It’s not only tragic when it comes to the emotional impact on the patients and the doctors and the nurses, it’s a huge financial issue as well.“

His work with the federal government during the development of the CANDOR Toolkit, and the RLDatix focus on integrating software solutions that support open communication, learning, and data analytics to reduce harm events, decrease liability, and improve patient safety is only the first step, Dr. McDonald says he wants to see more doctors, hospital and health system leaders, patient and family advocates, especially those connected to Patients For Patient Safety, US (PFPS US), an affiliate to the World Health Organization (WHO) advocating for the implementation of patient safety recommendations that are contained within the newly released President’s Council of Advisors on Science and Technology [PCAST] Patient Safety Report. He encourages the media to play a vital role in raising awareness and exerting pressure on policy makers to enact reforms as well. “The more the message can get out there, the more pressure gets put on federal policy makers” ultimately creating a safer, more transparent, and empathetic environment for both patients and healthcare professionals.