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.
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.
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.
Thanks to Beacon Press and Edelweiss for providing a review copy.