When We Do Harm: A Doctor Confronts Medical Error

by Danielle Ofri

Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it's a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there's no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation.

Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms.

Genres: Nonfiction, Medicine, Medical, Science, Memoir, Health, Biography

304 pages, Hardcover

First published April 1, 2020

About the author

When I started medical school, I had no idea that I would become a writer. I'd completed a PhD in the biochemistry of endorphin receptors, and planned to become a bench scientist with a once-a-week clinic to see patients.

But during residency, I fell in love with patient-care, and realized that I'd have to put bench research aside. After three years of training, I took off some time to travel. I spent 18 months on the road, working occasional medical temp-jobs to earn money, and then exploring Latin America for as long as my money would last.

It was during these travels, during this first true break from medicine, that I started writing down the stories of my medical training at Bellevue Hospital. I had no intentions about a book, or publishing at all, but I just needed to unload some of the stories that had built up over the years.

When I came back to medical practice, writing kept itself going in my life. Then I helped found the Bellevue Literary Review, which was another way to incorporate literature into medicine. Now, my time is split between clinical medicine, teaching, writing, editing, my newest hobby--cello, (and of course my three wonderful children!).

Reviews

[Petra X · Rating 5 out of 5]

This is a 10-star book. There are 17 chapters in this book, each addressing different issues that cause medical error which is a euphemism for doctors making you much sicker than you were when you went to see them about a problem. You may even find that along with a cessation in the troublesome symptoms there is a cessation of life. The medics have killed you!

The book is loosely hung around several cases of medical error, this provides a human context, stories to follow. But from those stories and a discussion of legal issues and trying to find out if the medic is guilty involuntary manslaughter or gross negligence, forget it. Unless you are a millionaire your chances of finding out anything, even something as small as an extra pill being given that actually didn't contribute to the harm, is almost nil.

Hospitals, medical insurance companies and doctors themselves are absolutely ruthless in their treatment of their victims. They will prevaricate, outright lie, cover up, close ranks, keep the case going until you've sold the house and your children's birthright. Or if things look like they are getting out of hand, try to settle for as small a sum as they can get away with and no explanation as to what happened. So, prevention is better than cure:

1. Have your entire medical history and all the medications you are presently taking on a single page to present to your doctor. They aren't going to read a file. Remember that the doctor isn't that interested in what happened to you 30 years ago, "Appendicitis" will do rather than the circumstances surrounding it and what medications you took. Leave out 'stubbed toe! If you have complex issues like chemotherapy, summarise it on the firsts page but you can have a second sheet with the nitty-gritty.

Compare your medication list with your doctor's at every visit to make sure that the medications, brands, doses are always up to date.

2. If you are in hospital, ask what medications you are being given and why, Write it in a notebook. If you aren't well enough, ask the nurse to write it for you.

3. If you don't think the doctors (it is usually the doctors) are being hygenic enough and you are really unwell and just lying there, fix a little sign on your chest, "Wash your hands first".

4. The most important tool you and the doctor have is personal conversation. If the doctor has not unglued their eyes from the computer say, that you know they have to write everything down, but "if you could just have one minute of their full attention, you will tell them the important stuff as concisely as possible."

If the doctor says, "I think you have X", ask them what makes them think that? Then ask, "Is there anything else it could be?" This will provide insight into the doctor's differential diagnosis and, if the treatment isn't successful, give you other avenues to consider.

There is a major issue that medics have. Whenever they prescribe anything, they have screens and screens of possible side effects (including extremely rare ones) to scroll through. These are supposed to be patient-specific, as in 56+ patient who has normal blood pressure and no symptoms other than .... but they aren't. This is the insurance companies trying to cover their asses. So the doctor may have to spend hours a day checking each box for each medication for each patient as well as much more "necessary" guff, that takes away time from the patients. The author says that for a prescription of Warfarin at Bellevue hospital she had 241 alerts of side effects, interactions and anything else the insurance company thought would protect them. To click each one of those.... so she got out her prescription pad and wrote it by hand (which took 7 seconds).

Some of the "guff" is the endless alerts from machines are meaningless. Alarms in the US are set to "cast the net as widely as possible because even one bad outcome could incur liability costs in the hundreds of millions of dollars to the manufacturers of these devices, the hospitals and EMRs. " An investigative report by the Boston Globe uncovered more than 200 deaths over 5 years related to alarm fatique. It found that nurses were bombarded with alarms, the vast majority of which were false. There were just so many alarms that they were losing their ability to alarm anyone and had become background noise

It's all about the money. This is what you get when you involve insurance companies aka legal protection rackets see Organized Crime: A Very Short Introduction . They are in it to make money, you are in it for your health these two objectives are frankly not compatible, although I don't suppose most of the US, including doctors, will agree with that. Not unless you've been refused the money for a treatment or a medication you need, then you will.

Notes on reading There is so much to write, so much necessary information about doctor error and why it happens and to some extent how to prevent it. But it's not a self-help type book, very far from it. This is an extremely detailed, deeply-researched, beautifully-written and unusual in this day of mass information, unique.

Review to come, but it needs some thinking about.

If you like these sort of books, exhaustively investigative and illuminating an aspect of 21st century life we scarcely think about (unless it affects us or our friends or family) in a very thought-provoking way, and decide to read it, you will get much from it. And because it is so well-written, enjoy it too.

[Morgan · Rating 5 out of 5]

This is an extremely scary book – so much so I had to read it in small doses.

Administrators, the people at the top who run institutions that deal with people’s lives, literally life and death situations every day, have a number one priority: Guess what it is?? Bottom Line. $$$$$$

Here are a few things that stuck out for me (a few among many):

Pg. 70: Dr. Ofri says “Improving communication between doctors and patients would be an excellent investment for preventing diagnostic errors.” A sentiment that is repeated several times throughout.

Pg. 125-6: “…adequate nurse staffing is critical……Skimping on nursing is a patient-safety hazard.”

The more medicine involves technology the more it offers the game of man vs machine. When the technology is not user friendly for medical staff – what then??
Pg. 186-7: “There is a growing sense that rather than these technologies helping us to serve our patients, the tables have turned so that ‘we’ have to serve the ‘technology’”.

Pg. 244: “Mandatory reporting [of medical error] would likely backfire…The only way to make such a system workable and accurate is to create a culture in which reporting an adverse event is a routine and ordinary event for medical professionals…”

After closing the book I said a prayer that I would not have to be anywhere near a hospital anytime soon…or ever! And most certainly never on July 1st.

This book is chilling, but so much of it is informative and may very well be helpful to you or a loved one at some point.

[Ellen Gail · Rating 4 out of 5]

A devastatingly sad and meticulous account of the human side of medical error.

"It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm." - Florence Nightingale

I've worked in pharmacy since 2013. One of the first things you are taught is that you are going to fuck up . It's not an if, it's a when. You do your best to reduce the risk and keep patient safety front and center, but it's a horrific inevitability.

Of course from the patient side of things, this is terrifying. I had to be admitted to the hospital for the first (and hopefully last) time, coincidentally, a year ago today. The fact that I worked three floors down and knew what meds I was being given and how to operate my IV pump didn't make it easier. Being woozy and nauseated and being wheeled into unplanned surgery is fundamentally frightening. Being in that OR room to work vs being on the table about to be knocked out is completely different.

And obviously I'm okay now, as I'm alive and well to write this review. But the idea of medical error hiding around every corner is real and scary no matter which side of the error you're on.

In When We Do Harm Danielle Ofri, an experienced physician and medical writer, tackles medical error and adverse events from both sides. Through her personal experiences and detailed heart-wrenching stories from patients' families, as well as reviews of published studies and talks with other professionals, Ofri takes us through a hazy and difficult to traverse world, where the stakes are high and the opportunities for error are seemingly endless.

This is NOT an easy read. And if you've had a loved one die recently, or traumatically in a hospital, I'd advise a heaping cup of caution heading into this. The patient stories are told remarkably well, but damn are they sad. They needed to be emotionally effective for this book to have the right impact, and it's successful in that. But I fucking cried, y'all. Jay's story especially made me heartsick.

All in all, When We Do Harm is a bit of a niche book I suppose. The statistics and safety initiatives around medical error don't exactly have mass appeal. But Danielle Ofri adds in the necessary humanity to make what could be an emotionless recital of statistics into a nuanced blend of fact and emotion.

It's a hard read, but an ultimately worthwhile one.

Thanks to Edelweiss and Beacon Press for the review copy!

[Emily · Rating 5 out of 5]

Excellent, as a healthcare provider I related viscerally so much to this author and book. I think it’s an important read for any consumer (read: all of us) of American medicine to understand just how easy it is to make medical error, and understand how to best prevent it in your own care. The case studies, especially of Jay, were gripping, informative, shocking and heartbreaking. This book will certainly change how I approach my practice and how I approach my own healthcare.

[Kazen · Rating 4 out of 5]

4.5 stars

So many things can go wrong in modern medicine, from misdiagnosing a disease to administering the wrong medicine with disastrous results. While there's all kinds of research about medical error most of it concentrates on procedural errors in inpatient settings, such as doctors forgetting to wash their hands before approaching a patient's bed. The literature ignores that most medical care is given in outpatient settings (doctors' offices, acute care) and many, many errors take place when a doctor tries to figure out what's wrong with you in the first place.

Add in mistakes caused by the computerized charting system, exacerbated by poor hand offs, and ignored by know-it-all doctors and we have a mess. Ofri leads us through it all in her approachable, engaging, and beautifully written style.

Here are some things I learned:

- According to one study (everything is clearly end noted, by the way) over 80 percent of errors are related to a problem in doctor-patient communication. Ofri points out that nearly every error she reviewed for the book could have been prevented, or had its harm minimized, had there been better doctor-patient communication.

- Capitalism in health care messes up so much stuff. Electronic medical records started as a billing system. Diagnoses are connected directly to billing codes, and there is no billing code for uncertainty. If there's a set of interrelated problems the doctor has to pick one as the diagnosis, risking that later doctors won't grasp the complexity of the issue.

- Don't get me started on malpractice lawsuits.

- Procedural errors can be fixed with checklists, but diagnostic errors are cognitive errors, and "fixing" how a doctor thinks is much, much harder.

- Hospital culture matters. Do the nurses feel comfortable speaking up when they see something wrong? Are patients' families listened to or dismissed?

- Many proposed solutions assume slow, methodical thinking when much of what doctors do is in the moment, under time pressure.

I love Ofri's writing style - suspenseful narrative nonfiction when going through a case, introspective and insightful when discussing her own experience with error.

There are days when I envy Sisyphus: at least it's the same stinking boulder he's pushing up the hill every day. For a doctor, it's a sea of boulders, any one of which - if missed - could come crashing down on one of my patients. Or on me, in the form of a lawsuit.

Make no mistake, many cases in this book are hard to read. A wife watching her husband die before her eyes without the medical staff doing anything to stop it. Mistreatment of a burn victim leading to his death, despite the efforts of nursing staff to get him better care. But the last couple of chapters give us hope, as well as concrete things a patient and their family can do to prevent medical error. Websites, professional organizations to contact, laws to be aware of, how to word requests to doctors, it's all here.

This is my favorite Ofri book to date, which is saying a lot. A must read if you have any kind of interest, and a natural follow-up to The Checklist Manifesto as Gawande only scratches the surface.

[Nicole · Rating 5 out of 5]

From a deeply personal level, knowing Jay for almost 20 years of my life, reading this was heart breaking. Being on the supportive side (gosh, I thought I was - but, I had NO clue what support meant in this case) and not knowing how alone Tara was and how hard she fought was difficult to read. But her, along with the other families, bravery to share their horrific pain needs to be known. I am far from clinical, and would have absolutely assumed that if I or my loved one was in the hospital - not even in the BMTU with extreme complications (still can’t believe it all), that I was in the right place. Like said in the book, if I was having a baby and needed a c-section - damnit, I would be immediately wheeled in for a c-section.

I hope this book gets read and helps all of those - patients, providers, caregivers - to take a look at the person. And never, ever stop fighting. People are imperfect, but every single person deserves to be seen.

Jay, you are so deeply missed and I know you know Tara did not fail you.

[Karen · Rating 4 out of 5]

Great book. Very well written, informative and engaging. I would give it 4 1/2 stars if I could, with the slight flaws being -
1) She tries a little too hard to be funny, and it sometimes lands wrong when she is writing about serious things.
2) While I appreciate her focus on systems and on reducing error by changing the systems, she goes a little easy on individual doctors. In Jay's case in particular, the errors came about because the doctors were arrogant and obnoxious. I think she does see this but is trying to look at all the possible causes of error and ways to avoid it, and maybe there's some professional courtesy involved in not being too hard on them. But sometimes it is actually a person's fault.

[Hillary DG · Rating 4 out of 5]

I clearly lost some empathy during training because I did not find this book “chilling” or “horrifying” as many readers have. Admittedly the information was largely not new to me, and I in fact got frustrated with Dr. Ofri’s somewhat repetitive writing style. But it’s just…another day on the job. Someone please fix EHR’s for the love of all that is holy or this is what we’re stuck with as an excuse for a healthcare system!

[CanadianReader · Rating 3 out of 5]

Rating: 3.5

[Deena Scintilla · Rating 4 out of 5]

A should-be read for anyone in the medical field, anyone who has had medical care, or anyone who has had a loved one who has required care. In other words, most. As a retired nurse, I have both seen and personally experienced medical errors. I've also witnessed an error of negligence that forever changed my late mother's life and felt the resistance (paranoia) when I requested copies of her medical records. To err IS human but to expect healthcare providers to never commit an error is unreasonable but they can be reduced. I used to tell my childbirth clients to remember, THEY hired their doctor and chose the hospital setting so they can change their minds as they are the "customer". Never be afraid to speak up, ask for 2nd opinions, or change providers.

[Kayla Kirkbride · Rating 4 out of 5]

I have really enjoyed both books I’ve read by Danielle Ofri. For this book in particular, her insights into medical error through anecdotes, scientific articles/interviews, and personal experience were both moving and sobering. When everyone is out to “Do No Harm”, who is to blame when things go awry? At what point is an individual liable within an imperfect system that is overwhelmed by staffing shortages, at the mercy of helpful technology, and suffocated by handoff-based teamwork? This book is directed toward patients, but healthcare providers would do well to note the advice Ofri gives as well. 4.5 stars

[Rachel · Rating 3 out of 5]

This book has a lot of good information about medical errors and their causes, and some information on how they can be avoided. It includes several patient stories, and one main, horrific story in detail.

But the book seemed scattered to me. I ended up skimming a lot of it; I could see the each subject, and could tell whether it had already been covered in the book and, if not, whether I found it of interest. There was a lot of unnecessary wordiness and a lot of repetition. The same material was covered in several different places in the book. Some of it was also details of inner hospital workings, computerized charting user interface design, insurance company policies, etc. These subjects are relevant, but for some of them, an overview is enough, and the details are overkill.

[Julie Stielstra · Rating 3 out of 5]

Full disclosure: Danielle Ofri accepted my short story "5 Star Hotel" for inclusion in the literary magazine she edits, the Bellevue Literary Review a few years ago. She was a terrific editor to work with.

This is a rambling, passionate, sometimes utterly harrowing examination of errors in medical care. I've worked in healthcare for thirty years, and can attest to the truth of what she observes in the ongoing effort to provide the right care to the right person for the right reason at the right time. The patient safety mission - to its credit - is data-driven, trying to focus on figuring out what went wrong, and then checking to see if improvement efforts actually had an effect. Not so much to its credit, the data measured is often punctuated with $, and tends to ignore how human beings (and doctors, nurses, and patients ARE human beings!) function, emotionally and neurologically. Health care trumpets how well it followed the aviation industry model of aspiring to zero errors, but as Ofri astutely points out: airplanes of a given model are machines, with the same dials, gauges, and levers, so once a pilot masters one, he or she can master the others. In medicine, every "pilot" (doctor) and every single individual "plane" (patient) is different, so one-size most definitely does NOT fit-all. She exudes frustration with the holy grail of the electronic medical record (EMR): a system originally designed to track every single item or activity that can be billed for does not translate well into a system of tracking health, disease, and the continuum of care, leading to workarounds, copy/paste shortcuts, hasty box-clicking, and profane outbursts. She is critical of the ever-shifting attention span of the quality-tracking people, and I've seen it myself first hand. A few years ago, every search of the literature I was asked to do was about catheter-associated bloodstream infections (CLABSIs) for a task force. There were inservices, posters, training sessions, newsletter features, etc. There was some improvement, so yay! And it was on to catheter-associated urinary tract infections (CAUTIs). And then on to healthcare-associated pressure injuries. And a month or so ago, a new task force is announced: we're back to CLABSIs as the numbers inched up again when the spotlight moved on.

Ofri also examines the effect of workload and staffing on errors. She describes an environment that sounds like sheer madness: lone physicians struggling to care for 40 patients at once, scheduling screwups, nurse shortages, EMR downtime, emergency admissions, overflowing waiting rooms, green interns, exhausted residents, and absolutely no time to THINK. She is a champion of nurses, extolling their value above rubies. One thing she does not address much is the high level of practitioner burnout - overburdened staff who are simply fed up, depressed, and angry, and how this might affect the care they give - or don't. The horrific case report of Jay, a 39-year-old man who goes into a septic spiral after a leukemia diagnosis, demonstrates a level of staff disconnection and indifference that makes me wonder about the basic emotional status of the clinicians involved.

I'm not quite sure who this book is intended for. It is lucidly written enough for lay people; yet it delves into the nitty-gritty of quality / performance improvement, checklists, etc., that may cause their eyes to glaze over. And while I stocked my hospital's medical library with books by Pronovost, Gawande, et al., (sometimes even at an administrator's request), they were rarely touched by anyone. Victoria Sweet's book Slow Medicine relates an appalling episode of her father's inappropriate care in a hospital where she had previously been invited to speak to the medical staff. Her message of connection to patients obviously dissipated as the door closed behind her. So while I will certainly add Ofri's book to the shelves where I work, I am not hopeful anyone will read it.

A couple minor things my copy-editing eye tripped on: even spell-check should have caught the several references to the medical chart as a "chronical."(p. 84) And a line about how the questions of interns force their supervising attendings to explain their reasoning, confusing "dissemble" with "disassemble" turns the sentence on its head entirely (p. 127).

Important information, to be sure, including suggestions for patients and families about keeping notes, asking questions (and which ones), and resources for assistance. Ofri sees patients, teaches, writes books and columns, edits a journal, has teenaged kids AND plays the cello. Her driven, high-intensity persona is apparent in this book, which can be exclamatory, sometimes flippant, sometimes darkly funny. I hope she's not heading for burnout - we need her.

[Anne · Rating 2 out of 5]

The 2 case studies were riveting, devastating, and very well written - I even cried. So the 2 stars are for that.

As for the rest, which makes up the majority of the book? Rambling, depressing and ultimately left me personally feeling hopeless - the very systems in place that cause SO many medical errors are not going back into the toothpaste tube. There really is no solution offered other than "there needs to be better communication between doctors and patients."

Well, duh. But doctors literally don't have time for this - they're already stretched way too thin as it is. I have compassion and patience for most medical professionals (with a few exceptions - the case study stories are horrifying, to put it mildly).

Wish I hadn't read it, to be honest.

[Nic · Rating 5 out of 5]

Reading Danielle Ofri's latest book on medical errors has been cathartic. It's terrible that this happens too often, but there's a bit of relief in knowing you're not the only one. For example, coming from a rural area, it may feel as if doctors, from the big cities, larger hospitals, and teaching universities, look down on you, perhaps, for being poor, or having an accent, etc. Hearing that it's more of a defensive mechanism, on the part of doctors, relieves those thoughts, somewhat. Ofri points out that rural hospitals usually are not equipped for handling complex care and emergencies The defining medical challenge for rural hospitals has always been attracting - and retaining - enough doctors. 166 Most larger hospitals are now staffed with full-time emergency medicine doctors, but rural hospitals have to make do with the old system. 167

What's most frustrating to me is the constant talk, in the larger universities, on attracting students from rural areas in the hopes that these students will return to their hometowns to provide more advanced medical training and relief. (I’m still feeling rather burned that I was twice overlooked for the PA program, even though I’m the rural student poster child. Hello?!!) I don't see this system working fast enough, if at all, in many rural areas. Maybe it would be better to have clinical rotations in rural hospitals and bring rotating teams into these places. Bring the universities and students to the rural hospitals. I think it would be a win/win, training new students in understanding social determinants of health, as well as creating more communication, positive collaborations, and teaching between the rural doctors and the university doctors.

From my perspective, there are more errors in rural hospitals, and this seems due to a lack of advanced technologies, equipment, and specialty doctors. My family has lost two members due to rural healthcare and lack of access to more advanced facilities. In one case, it was a lack of recognition of zebra hoof prints, which probably would have been a hard catch even in the most advanced facility. For that reason, it was a more forgivable, understandable error for the family. However, even over 40 years later, the loss is strongly felt, and the seed of distrust has been planted. Over 40 years later, the tombstone remains marking the gravesite of my 18 year old aunt. Recently, too recently, it has been my own father. A routine, standard surgical procedure, which we thought could be entrusted to this rural hospital, did not go well. Several surgeries and hospital transfers later proved too demanding on his body. Recently, I had undergone my CPR renewal training. As a student assigned to a clinical rotation, in the University hospital where my father was airlifted to, I was nervous in anticipation of witnessing my first code. I never could imagine that less than 2 weeks after CPR training my father's code would be the first I'd witness. I had great faith in the University hospital and never doubted they would save him, and they did! The surgeon there had a successful surgery in repairing the errors done. He was on the mend!! However, there were too many surgeries, and in the end his body couldn't handle the trauma. Now as a family we mull it over again and again, why didn't we skip the rural hospital, we shouldn't have trusted, but we thought it was routine and that it'd be okay. It's not fair.

Life is not fair, but it often seems more unfair for those on the fringes. I hope that Ofri's book brings about more changes, in the systems in place, to help reduce and prevent future errors.

In a strange way, death is actually one of the steps of the code. It isn't listed in the algorithm, of course, but it's there. The first step. Everyone knows it, but no one will say it. Even though the patient has already died from the devastation of disease, the code presses on until someone "calls it." Then, and only then, can death be acknowledged. It is a wrenching combination of human grief and quotidian bureaucracy...In all cases, life had already ceased for the patient. In fact, life had ceased before the code started. That was the time when the patient had stopped breathing or the heart had stopped beating. That was when the patient had really died. Yet we officially record the time of death as the moment when we adjourn our battle, not the moment the cells have adjourned theirs. 83

One area that has largely gone under the radar is the working condition of nurses. Because of chronic staffing shortages, many nurses end up working overtime. In some hospitals, what is meant to be a stopgap measure has become standard operating procedure...A study of more than 232,342 surgery patients examined nurse-to-patient ratios and mortality. To no one's surprise, the heavier the patient load per nurse, the higher the mortality rate. The researchers calculated that for every additional patient added to a nurses' roster, the odds of a patient dying within 30 days increased by 7%. Nurse burnout goes up by 23%....Moreover, they noted that mortality also increased by 4% per shift when there was high patient turnover - admissions, discharges, transfers. These events require significant nursing time, often at the expense of the other patients on the ward. This study underscores that adequate nurse staffing is critical and that staffing needs to be adjusted upward at busier times and for sicker patients. Skimping on nursing is a patient-safety hazard. 126

What is possible to say with certainty, however, is that a beloved man was ripped from his family, leaving a gaping, ragged wound that no protocol or algorithm or lawsuit could ever heal. 169

[CatReader · Rating 5 out of 5]

As a fellow physician, this book was very hard to read but also very important. I too have seen many incidents of medical error, from the types mentioned in this book to more esoteric diagnostic errors contingent on laboratory testing (my area of specialty) that often go unrecognized by ordering providers. I've also had loved ones pass away or suffer complications as a result of medical errors -- and I totally get where Dr. Ofri is coming from when she talks about the importance of vigilance from patient's loved ones (or the patient themselves, if they are able to) while receiving medical care, though this isn't realistic for many.

My opinion, like Dr. Ofri's, is that most medical errors are systemic and multifactorial, and thus require systemic and multifactorial solutions. Yes, there are sometimes bad actors (fellow physicians, nurses, hospital administrators, etc.) who act with malice, greed, or laziness, but I think for the most part people in the healthcare system are acting with good intentions and doing their best despite significant challenges (staffing, resources, unrealistic workloads, compassion fatigue, inadequate sleep, burnout, etc.).

Further reading:
On systemic improvement (and pitfalls) in medicine
The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age by Robert Wachter, MD -- discussed in this book
The Checklist Manifesto: How to Get Things Right by Atul Gawande, MD
Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande, MD

On medical error/harm from a historical/public health standpoint:
What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City by Mona Hanna-Attisha, MD
Lifelines: A Doctor's Journey in the Fight for Public Health by Leana Wen, MD
The Radium Girls: The Dark Story of America's Shining Women by Kate Moore -- I found lot of parallels between the patient vignettes Ofri explores and the experiences of the "radium girls"
The Immortal Life of Henrietta Lacks by Rebecca Skloot

[Richard · Rating 5 out of 5]

This is one of the best books I've read on problems and how to solve them. It is an even-handed discussion of medical errors and some of the causes. Unlike a lot of books/articles of this type, no simple solution is proposed - because there are no simple solutions. Instead, there is an examination of possible ways in which the system could be improved to catch mistakes before they affect a patient and how those possible solutions can introduce other problems into the system.

I was very impressed by the impartial evaluations and assessments of errors. "Yes, this was an error - but here's how it happened, and it could have happened to anyone." Another good point comes in the discussion of how a number of errors are not problems because they have no affect on patient care (the diagnosis was wrong, but the treatment for both the correct and incorrect diagnoses is the same) - but that they should be considered "near misses" and so investigated.

One thing I enjoyed is reading about how the medical system appears from the family's side of things, especially when the author's daughter was in the system and the author had to deal with the situation from the other side, so to speak.

If you're looking for a well-reasoned and thought out explanation of how errors can occur, along with some very thought-provoking ideas on how the system can be improved, this book is for you. If you're looking for a book to justify your belief that all medical errors are preventable and should be dealt with severely, or if you're looking for a book to show that errors made by medical professionals are all justifiable, this book is not for you.

[valiantdust · Rating 5 out of 5]

A must read for anyone who will come into contact with the healthcare system - i.e., everyone. Dr. Ofri tackles the much-publicized statistic that the third highest leading cause of death in the US (and incidentally Canada) is medical error. In a complex but accessible way, Ofri teases analyses this stat to help the reader understand why medical errors are so common, what needs to change in medicine to minimize them, and what patients and other clinicians can do about it. She closes with the conclusion that medical error as the third-highest leading cause of death is likely inflated, but that any amount of error leading to death is not acceptable, and also that the major challenge is minimizing the errors that don't lead to death but nonetheless cause harm. Overall, I thoroughly enjoyed this book. Ofri has a kind of intellectual humility that doesn't slide into self-denegration, a critical eye that illuminates instead of judges, and a voice that is erudite but also relatable.

[Olivia · Rating 4 out of 5]

I read this book for a project at work. It's definitely not my normal kind of read- I avoid anything overtly medical in my books- but it was an important book with relevant stories to tell.

Essentially, this book is about medical error- what is it, why does it happen, how do patients and families cope with it, how do healthcare workers cope with it, and what can we do moving forward? Lots of big questions, with some not-so-satisfactory answers (largely because healthcare is an institution with institution-sized problems).

The stories in this book are absolutely maddening in the worst way. Still, the author provides some hope and best practices to follow at the end, to give at least a little bit of advice that might help someone.

[Marco · Rating 4 out of 5]

3.8*

A balanced book on the perils of hospitals and doctors nowadays, from someone quite in the know.

This is one of those books which feel 40% longer than they should be. I can honestly say that after the first 25% or so I didn't learn anything new per se, just got more and more examples of what was explained before.

But maybe it's just a matter of taste - I can see how some people will find the minutia of the cases she narrates interesting.

[Kimberly · Rating 4 out of 5]

Like literally any other healthcare worker, I dread inadvertently causing harm, either by action or failure to act, to a person under my care. This book did not help that fear, lol. In all seriousness, this is a very important book for both patients and practitioners. It reaffirms my need to be an advocate, to ask the silly questions when I need clarification, to be “annoying” and “insistent” if I know in my gut something is wrong, both for my own care and in my nursing career.

[Sammy · Rating 5 out of 5]

Truly an amazing book for anyone who is considering, Currently obtaining a medical degree, or anyone that is in the field that needs a reminder of what we do every day. Emotionally grasping, riveting, and what truly is amazing, The book pertains to real world issues that all of us face in the medical field.

[Shruthi · Rating 5 out of 5]

This is truly a phenomenal read. If you're someone who has ever received medical care, will receive medical care, have loved someone who has received or will receive medical care or are in the healthcare field then you have to read this.

This is a very comprehensive look at medical errors; why they happen, what you can do after and how we can reduce them. I particularly liked the case studies and the non-judgmental tone the author carried throughout the book.

[Gijs Limonard · Rating 4 out of 5]

Excellent work on iatrogenesis; suffering caused by the healer; some quotes;

"Robert Moser, a resident at Brooke Army Medical Center, was one of the first people to take a hard look at the downsides of medical care. In a 1956 paper in the New England Journal of Medicine, he described “diseases that would not have occurred if [the] therapeutic procedure had not been employed.” This paper may have been the first to survey the damages that we clinicians do, even in the name of good medical care. He titled his paper “Diseases of Medical Progress” and found that about 5% of patients experienced these."

"One of the first studies to examine these questions in a rigorous way was the Harvard Medical Practice Study.6 The researchers studied fifty-one hospitals in the state of New York over the calendar year of 1984. (If dirty laundry was to be aired, presumably these Harvard researchers preferred it to be of New York origin, rather than from their own hospitals in Massachusetts!) They examined 30,121 randomly selected charts and recorded the number of adverse events, which they defined as unintended injuries resulting from medical care. The study found that 3.7% of hospitalizations resulted in a medical injury, of which 14% were fatal. If the study results were extrapolated to all residents of New York State, this would mean that there were nearly one hundred thousand injuries (including 13,451 deaths and 2,550 cases of permanent disability) as a result of hospital care in 1984."

"“The key,” he said, “is recognizing that changing practice is not a technical problem that can be solved by ticking off boxes on a checklist but a social problem of human behavior and interaction.”"

[Jennifer · Rating 4 out of 5]

What else could it be? …… Is there anything we can’t afford to miss? Did I simply accept the first diagnostic that came to mind? Did someone else—patient, colleague——already put on a diagnostic label that’s biasing me? Was the patient recently evaluated for the same complaint? Am I distracted or overtired right now? Is this a patient that I don’t like for some reason? Is this a patient I like too much (family member, friend, colleague)? (Process checklist)

Ely, a family physician in Iowa, developed a convenient set of lists for outpatient use (dizziness, abdominal/pelvic pain, diarrhea, headache, insomnia, etc.) and then listed a dozen or two of the most common causes, with a few tricky ones labeled “commonly missed” and a few serious ones labeled “do not miss.” It’s a quick way for a doctor to run down a list and make sure she hasn’t missed anything.

https://pie.med.utoronto.ca/DC/DC_con... (Content checklist)




Core IM podcast —-NYC PROFS (adrenal insufficiency example)




Mnemonic: I-PASS (for handoff procedures) —-study showed 23% decrease in medical errors

I: Illness Severity: how sick is the patient?
P: Patient Summary: a succinct nugget of the patient’s illness and treatment plan
A: Action Items: the to-do list
S: Situational Awareness and Contingency Plan: what to do if X happens
S: Receiver Synthesis: the person taking over gives a quick recap



“Errors make sense when you understand the cognitive shortcuts that lead to them, and that’s what Dror tries to teach nurses and doctors. When he helps hospitals set up simulation programs, he makes sure the staff get to experience errors. Instead of having the patient ultimately survive—-as is the usual case in most simulations—-Dror’s exercises make sure the patient dies a few times. With high-stakes situations such as sepsis, cardiac arrest, intubation, surgical mistakes, and medication errors, it is important for the participants to experience things going wrong as a result of their decisions and actions. The experiential aspect of the training offers the strongest chance of transferring the knowledge to situations with real patients.
Simulation is preferred because personal experience with such disasters might actually be too traumatic to be effective. I remember when I was a resident and botched a case of diabetic ketoacidosis, nearly putting the patient in cardiac arrest. I was only a few days out of internship and was so devastated by the experience that I could hardly scrape my sorry self off the linoleum floor, much less think analytically about what had transpired and how to do better next time. So I appreciated Dror’s preference for simulation over personal experience. It wouldn’t be a stretch to assume that patients also prefer simulation as the place for medical staff to experience the Terror of Error.”



“First Night on Call” exercise, simulation program developed by team of educators at NYU for 4th year med students (Adina Kaley and Sondra Zabar) ——the students have 10 minutes to handle these tense clinical situations—-created by remarkably convincing actors—-and then they have to present the cases to (real) chief residents or attending physicians to be grilled on the clinical details. After that, the students engage in what many feel is the most valuable part—-a group discussion analyzing their experiences in the simulation. A faculty member facilitates the discussion, but it’s the students who dig through the issues—-medical, emotional, logistical, hierarchical—that are unearthed. The students consistently rank the simulation as one of the most effective learning experiences in medical school.





“So what can you do as a patient to minimize harm? For starters, it’s important to know your own medical history. This may seem like an obvious point, but I’m always surprised by how many patients have trouble with this. It’s a good idea to make a one-page list that has your basic diagnoses, your current medications and the dosages, what surgeries you’ve had, and what you are allergic to.
Resist the urge to create a forty-page, single-spaced, cross-referenced treatise that lists every cold you’ve had, your teenage acne, your stubbed toes, and the fact that garlic powder gives you the hiccups. Keep it simple, clear, and relevant. (An exception can be made it you’ve had a complex treatment such as chemotherapy or a heart transplant. For that, you can keep a separate sheet that in lides the nitty-gritty details.)
Having a basic info sheet on hand for any medical encounter can help prevent basic errors like prescribing something you are allergic to or that is contraindicated based on one of your conditions.
Medications change frequently, so it is wise to compare your medication list to your doctor’s list at every visit. The most practical way to do this is to sweep your pill bottles into a bag and bring it with you. I find this to be the most helpful method, because sometimes there are medications prescribed by other doctors that I wouldn’t otherwise know about. Or the dosage of a medication was changed at an urgent-care visit. If you take supplements, herbal medications, or over-the-counter meds, throw them in their own bag and bring it along too.
When it comes to minimizing diagnostic error, the focus should be on the conversation. The conversation between the patient and the medical team is the single most critical diagnostic tool, so you want to make sure it does not get short shrift. If your doctor has not unglued her eyes from the computer screen for the entire visit and is robotically filling in check boxes, you are well within your constitutional rights to politely point that out. You could say something like, ‘I know that you have to write all this down in the computer, but if you could give me one minute of your full attention, I’ll tell you the important stuff as concisely as possible.’ You want to be sure you are having a thorough, engaged conversation with your doctor so that your symptoms can be adequately explored.
And when your doctor says, ‘I think you have X,’ you should ask,’What makes you think so?’ This will help you understand how convinced (or not) your doctor is by the data. Then ask, ‘Is there anything else that it could be?’ This will provide insight into the doctor’s differential diagnosis and clinical reasoning. If you want to press further, you could ask, ‘Is there anything we can’t afford to miss?’ If your doctor turns out to be someone who snaps to quick diagnosis, these simple questions will force her to engage in the reasoning process she should have done all along.
Infection is one area where there is a practical strategy for self prevention. Make sure you witness every medical person wash their hands before they touch you. Make a joke if you must, be self-deprecating, neurotic, or forceful if you need to be, channel your inner Ignaz Semmelweis if you can, but do whatever it takes to keep germ-laden hands off you until they’ve been washed with soap or thoroughly rubbed with a waterless disinfectant. (If your doctor or nurse acts affronted, maybe try asking them in which of Semmelweis’s two obstetric clinics would they want to get their medical care?)
For hospitalized patients (and for anyone undergoing extensive outpatient treatment such as chemotherapy), perhaps the most critical safety feature is the presence of another person. It is simply too much to ask a person who is acutely ill or receiving bulldozer-level medical treatments to keep track of the intricacies of what is going on. If you are puking your guts out or bone-rattling from a 104-degree fever, you have enough in your plate. You’ve earned your dispensation to focus on the immediacy and awfulness of being sick.
The second person has to be your eyes and ears. That person should keep a notebook at the bedside and write down—and ask about—every single thing that transpires. What is the diagnosis? What is this medication for (and how do you spell it)? What side effects should you look out for? What are today’s blood test results? Who is this 37th person in a white coat? Why is the patient getting a CT scan? (And how good is a CT scan for this issue?) When should we expect a response to the treatment?
It can be hard to speak up. And even when you do—as Tara experienced—it can be even harder to effect change. Still, family members and friends are essential for keeping tabs. The very act of having the medical team clarify each step—and, crucially, the thought process behind each step— is a good check in common medical errors. The staff might give you a Tony Award for being the most annoying family member on the ward, but that’s okay. (You can always drop off a box of cookies to soothe ruffled egos.) Asking questions and writing down the details provides a paper trail during a confusing journey. And should something go wrong, it’s an invaluable tool for reconstructing the timeline.”

[AltLovesBooks · Rating 5 out of 5]

I'm fortunate that in my thirtysomething years on this planet I haven't required anything more serious than some antibiotics for strep, and the only time I've gone under the knife was for elective cosmetic surgery. My husband, likewise, is healthy as a horse (knock on all available wood). So I approached this book very much as an outsider with a general interest in, well, generally all things, and the premise sounded interesting. I was extremely surprised at how much I walked away with from this book, even having no ongoing medical conditions myself.

The book is structured in such a way that the author's points are mixed in with actual cases and examples emphasizing what she finds important. There's also two larger cases that span a good chunk of the book, one involving a patient named Jay and the other a burn victim named Glenn, that she uses to drive home points all throughout the book. I really liked this approach, and also appreciated the fact that everything was easy to understand and approachable.

The premise can be a little scary for some people, that mistakes can happen, but people are people and this is very hard to overcome. The author goes to great lengths explaining all the safeguards and thought processes in place to prevent mistakes from happening, and then also discusses all the ways these can be bypassed in the name of expedited care and overworked staff. The specific mistakes involved in the two larger cases (Jay's and Glenn's) are outlined at the very end of the book, and the author discusses how these mistakes and others can be avoided by the medical industry. Chapter 16 especially was good to read, as the author discusses what a patient can do to protect themselves, and also provides various resources to reach out to if negligent treatment is suspected.

All in all I enjoyed this book a ton and walked away with some valuable information that I'll hopefully carry with me as my husband and I get older.

[Kbeckermann · Rating 5 out of 5]

I love Ofri's writing. When We Do Harm didn't disappoint. As she explores medical error she shares personal experience, presents research, talks about the human side of the experience and uses just amount of humour to explore errors and near misses.

[Miguel · Rating 4 out of 5]

The basic question addressed in this book is whether medical error is as prevalent as is often reported and such a high cause of death. The statistic itself appears controversial as it’s not universally accepted as, say, heart failure or cancer as leading causes of fatality. The author, who is also a medical doctor, takes the reader through two rather heart wrenching cases, one of which was the husband of an ER nurse in which he received substandard care that ultimately wound up in a long medical malpractice suit. Ofri does a good job balancing the human and scientific side of the debate, calling out the over reliance on filling out checkboxes and ENR’s and is open to allowing more technology to enter into practice to counterbalance potential sources of doctor error.

[Jara Alvarez · Rating 5 out of 5]

This is such a good book that every healthcare professional should read! It was engaging and also provided practical solutions that can be implemented to help keep patients safe.

[Scott Pearson · Rating 5 out of 5]

Medicine, wherever it is practiced, involves heavy things that are not for the faint of heart. Outcomes sometimes involve death, and errors are not always (or often) easy to spot. Poor outcomes can haunt doctors and nurses both professionally and personally – almost as much as they can haunt the families of patients. Nonetheless, in the United States, no comprehensive system exists to monitor medical errors. As Ofri details in this well-written and timely book, this situation neither provides justice to the needs of patients and their families nor allows the medical system to learn from its mistakes.

This book probes two medical cases that were particularly error-filled. One involved a patient with leukemia, a form of cancer, and the other involved a patient whose case was clearly mismanaged at several points. Errors accumulated in each case, and each was met with silence and obfuscation by the medical establishment. At the outset, positive outcomes were not guaranteed, but compounding errors guaranteed horrific outcomes involving death. Families of both patients sought corrective measures for the causative systemic problems, but despite noble intentions and proper efforts, neither family were successful.

Ofri holds the Danish medical system as an example. In this small country, parliament passed a Patient Safety Act of 2005 to set up a system that judges and potentially compensates patients for negative outcomes. Gone were the excesses of legal case and drama of the courtroom; also gone were the huge settlements for hyperbolic cases. In its place was something more equitable and more enlightened. Instead of requiring excessive, provable harm like death or permanent disability, the Danish system just required preponderance of the evidence for more mundane claims.

The author rightly questions whether such a system could ever succeed in the United States. For one, we are more brashly capitalistic and individualistic than Denmark. Further, our country is much larger and more diverse. We also have a long and deep suspicion of centralized medical data collection. But the Danish system simply seems fairer and more just to both parties. In it, the doctor-patient relationship never transforms into an adversarial duel filled with legal tactics. Medicine at its best aims to be humane; doesn’t this system better fit that ethos?

This work can find an obvious home among American healthcare workers, whether doctors, hospital administrators, or nurses. Particularly those with patient contact should attend to Ofri’s clear message. Policymakers and administrators of public health might also want to give this one a read because of obvious import into government. Ofri’s call may yet be a bit early for legislation to be passed, but my experiences concur that it needs to be heard. It deserves to be on the radar for public health advocates once the challenges of COVID dissipate. I’m glad that I found and read this book.