NOTES

CHAPTER ONE: JUMBO JETS CRASHING

1. M. A. Makary and M. Daniel, “Medical Error—the Third Leading Cause of Death in the US,” British Medical Journal (BMJ) 353 (2016): 2139–44, www.ncbi.nlm.nih.gov/pubmed/27143499.

2. L. T. Kohn et al., To Err Is Human: Building a Safer Health System (Washington, DC: National Academies Press, 2000), www.ncbi.nlm.nih.gov/pubmed/25077248.

3. R. H. Moser, “Diseases of Medical Progress,” New England Journal of Medicine 255 (1956): 606–14, www.ncbi.nlm.nih.gov/pubmed/13369682.

4. E. M. Schimmel, “The Hazards of Hospitalization,” Annals of Internal Medicine 60 (1964): 100–110, www.ncbi.nlm.nih.gov/pubmed/12571347.

5. E. M. Schimmel, “The Physician as Pathogen,” Journal of Chronic Diseases 16 (1963): 1–4, www.ncbi.nlm.nih.gov/pubmed/13991732.

6. T. A. Brennan et al., “Incidence of Adverse Events and Negligence in Hospitalized Patients—Results of the Harvard Medical Practice Study I,” New England Journal of Medicine 324 (1991): 370–76, www.ncbi.nlm.nih.gov/pubmed/1987460.

7. L. L. Leape, “Error in Medicine,” Journal of the American Medical Association (JAMA) 272 (1994): 1851–57, www.ncbi.nlm.nih.gov/pubmed/7503827.

8. E. J. Thomas et al., “Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado,” Medical Care 38 (2000): 261–71, www.ncbi.nlm.nih.gov/pubmed/10718351.

9. S. M. Berenholtz et al., “Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit,” Critical Care Medicine 32 (2004): 2014–20, www.ncbi.nlm.nih.gov/pubmed/15483409.

10. P. J. Pronovost et al., “An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU,” New England Journal of Medicine 355 (2006): 2725–32, www.ncbi.nlm.nih.gov/pubmed/17192537.

11. A. B. Haynes, “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” New England Journal of Medicine 360 (2009): 491–99, www.ncbi.nlm.nih.gov/pubmed/19144931.

12. D. R. Urbach et al., “Introduction of Surgical Safety Checklists in Ontario, Canada,” New England Journal of Medicine 370 (2014): 1029–38, www.ncbi.nlm.nih.gov/pubmed/24620866.

13. C. Dreifus, “Doctor Leads Quest for Safer Ways to Care for Patients,” New York Times, March 8, 2010, www.nytimes.com/2010/03/09/science/09conv.html.

14. L. L. Leape, “The Checklist Conundrum,” editorial, New England Journal of Medicine 370 (2014): 1063–64, www.ncbi.nlm.nih.gov/pubmed/24620871.

15. M. Best and D. Neuhauser, “Ignaz Semmelweis and the Birth of Infection Control,” BMJ Quality & Safety 13 (2004): 233–34, www.ncbi.nlm.nih.gov/pubmed/15175497.

16. C. J. Gill and G. C. Gill, “Nightingale in Scutari: Her Legacy Reexamined,” Clinical Infectious Diseases 40 (2005): 1799–1805, www.ncbi.nlm.nih.gov/pubmed/15909269.

CHAPTER THREE: MAKING—OR MISSING—THE DIAGNOSIS

1. M. L. Graber, “The Incidence of Diagnostic Error in Medicine,” BMJ Quality & Safety 22 (2013): ii21–ii27, www.ncbi.nlm.nih.gov/pubmed/23771902.

2. H. Singh et al., “Types and Origins of Diagnostic Errors in Primary Care Settings,” JAMA Internal Medicine 173 (2013): 418–25, www.ncbi.nlm.nih.gov/pubmed/23440149.

3. M. L. Graber et al., “Cognitive Interventions to Reduce Diagnostic Error: A Narrative Review,” BMJ Quality & Safety 21 (2012): 535–57, www.ncbi.nlm.nih.gov/pubmed/22543420.

CHAPTER FIVE: DIAGNOSTIC THINKING

1. P. Rajpurkar et al., “Deep Learning for Chest Radiograph Diagnosis: A Retrospective Comparison of the CheXNeXt Algorithm to Practicing Radiologists,” PLoS Medicine 15, no. 11 (November 20, 2018): e1002686, www.ncbi.nlm.nih.gov/pubmed.

2. N. Riches et al., “The Effectiveness of Electronic Differential Diagnoses (DDX) Generators: A Systematic Review and Meta-Analysis,” PLoS ONE (March 8, 2016), www.ncbi.nlm.nih.gov/pubmed/26954234.

3. J. W. Ely et al., “Checklists to Reduce Diagnostic Errors,” Academic Medicine 86 (2011): 307–13, www.ncbi.nlm.nih.gov/pubmed/21248608.

4. Perioperative Interactive Education, “Diagnostic Checklist,” Toronto General Hospital, Department of Anesthesia, pie.med.utoronto.ca/DC/DC_content/DC_checklist.html, accessed September 4, 2019.

5. M. L. Graber et al., “Developing Checklists to Prevent Diagnostic Error in Emergency Room Settings,” Diagnosis (Berl) 1 (2014): 223–31, www.ncbi.nlm.nih.gov/pubmed/27006889.

6. H. Singh and L. Zwaan, “Reducing Diagnostic Error—A New Horizon of Opportunities for Hospital Medicine,” Annals of Internal Medicine 165 (2016): HO2–HO4, www.ncbi.nlm.nih.gov/pubmed/27750328.

7. E. P. Balogh, B. T. Miller, and J. R. Ball Jr., eds., Improving Diagnosis in Health Care (Washington, DC: National Academies Press, 2015), www.ncbi.nlm.nih.gov/books/NBK338600.

CHAPTER SEVEN: FOR THE RECORD

1. Robert Wachter, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (New York: McGraw Hill, 2015).

2. D. R. Murphy et al., “The Burden of Inbox Notifications in Commercial Electronic Health Records,” JAMA Internal Medicine 176 (2016): 559–60, www.ncbi.nlm.nih.gov/pubmed/26974737.

3. D. C. Radley et al., “Reduction in Medication Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems,” Journal of the American Medical Informatics Association 20 (2013): 470–76, www.ncbi.nlm.nih.gov/pubmed/23425440.

4. B. J. Drew et al., “Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Study of Intensive Care Patients,” PLoS One (October 22, 2014), www.ncbi.nlm.nih.gov/pubmed/25338067.

5. Liz Kowalczyk, “Patient Alarms Often Unheard, Unheeded,” Boston Globe, February 13, 2011, http://archive.boston.com/lifestyle/health/articles/2011/02/13/patient_alarms_often_unheard_unheeded.

6. M. L. Graber et al., “Electronic Health Record–Related Events in Medical Malpractice Claims,” Journal of Patient Safety 15 (2019): 77–85, www.ncbi.nlm.nih.gov/pubmed/26558652.

7. “Case Counts,” Centers for Disease Control and Prevention, www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html, accessed December 5, 2019.

8. Josh Vorhees, “Everything That Went Wrong in Dallas,” Slate, October 16, 2014, http://www.slate.com/articles/health_and_science/medical_examiner/2014/10/dallas_ebola_timeline_the_many_medical_missteps_at_texas_health_presbyterian.html; D. K. Upadhyay et al., “Ebola US Patient Zero: Lessons on Misdiagnosis and Effective Use of Electronic Health Records,” Diagnosis 1 (2014): 283–87, www.ncbi.nlm.nih.gov/pubmed/26705511.

9. NBC News, “Texas Hospital Makes Changes after Ebola Patient Turned Away,” October 3, 2014, www.nbcnews.com/storyline/ebola-virus-outbreak/texas-hospital-makes-changes-after-ebola-patient-turned-away-n217296.

10. Robert Wachter, “What Ebola Error in Dallas Shows,” USA Today, October 12, 2014, www.usatoday.com/story/opinion/2014/10/12/what-ebola-error-in-dallas-shows-column/17159839.

CHAPTER NINE: ON THE CLOCK

1. BBC News, “Leicester Doctor Guilty of Manslaughter of Jack Adcock, 6,” November 4, 2015, www.bbc.com/news/uk-england-leicestershire-34722885.

2. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (Washington, DC: National Academies Press, 2009), www.ncbi.nlm.nih.gov/pubmed/25009922.

3. K.Y. Bilimoria et al., “National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training,” New England Journal of Medicine 374 (2016): 713–27, www.ncbi.nlm.nih.gov/pubmed/26836220.

4. S. Sen et al., “A Prospective Cohort Study Investigating Factors Associated with Depression during Medical Internship,” Archives of General Psychiatry 67 (2010): 557–65, www.ncbi.nlm.nih.gov/pubmed/20368500; S. C. Fitzgibbons et al., “Long-Term Follow-Up on the Educational Impact of ACGME Duty Hour Limits: A Pre-Post Survey Study,” Annals of Surgery 256 (2012): 1108–12, www.ncbi.nlm.nih.gov/pubmed/23069864; C. L. Bennett et al., “Association of the 2003 and 2011 ACGME Resident Duty Hour Reforms with Internal Medicine Initial Certification Examination Performance,” Journal of Graduate Medical Education 9 (2017): 789–90, www.ncbi.nlm.nih.gov/pubmed/29270281.

5. C. P. Landrigan et al., “Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units,” New England Journal of Medicine 351 (2004): 1838–48, www.ncbi.nlm.nih.gov/pubmed/15509817.

6. J. H. Silber et al., “Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules,” New England Journal of Medicine 380 (2019): 905–14, www.ncbi.nlm.nih.gov/pubmed/30855740.

7. L. A. Riesenberg et al., “Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature,” Academic Medicine 84 (2009): 1775–87, www.ncbi.nlm.nih.gov/pubmed/19940588.

8. A. J. Starmer et al., “Changes in Medical Errors after Implementation of a Handoff Program,” New England Journal of Medicine 371 (2014): 1803–12, www.ncbi.nlm.nih.gov/pubmed/25372088.

9. D. M. Olds and S. P. Clarke, “The Effect of Work Hours on Adverse Events and Errors in Health Care,” Journal of Safety Research 41 (2010): 153–62, www.ncbi.nlm.nih.gov/pubmed/20497801.

10. L. H. Aiken et al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” JAMA 288 (2002): 1987–93, www.ncbi.nlm.nih.gov/pubmed/12387650.

11. J. Needleman et al., “Nurse Staffing and Inpatient Hospital Mortality,” New England Journal of Medicine 364 (2011): 1037–45, www.ncbi.nlm.nih.gov/pubmed/21410372.

12. J. Q. Young et al., “July Effect: Impact of the Academic Year-End Changeover on Patient Outcomes: A Systematic Review,” Annals of Internal Medicine 155 (2011): 309–15, www.ncbi.nlm.nih.gov/pubmed/21747093.

13. L. A. Pauls et al., “The Weekend Effect in Hospitalized Patients: A Meta-Analysis,” Journal of Hospital Medicine 9 (2017): 760–66, www.ncbi.nlm.nih.gov/pubmed/28914284.

14. A. S. Walker et al., “Mortality Risks Associated with Emergency Admissions during Weekends and Public Holidays: An Analysis of Electronic Health Records,” Lancet 390 (2017): 62–72, www.ncbi.nlm.nih.gov/pubmed/28499548.

CHAPTER TEN: WHAT YOU SEE

1. M. F. MacDorman et al., “Trends in Maternal Mortality by Sociodemographic Characteristics and Cause of Death in 27 States and the District of Columbia,” Obstetrics & Gynecology 129 (2017): 811–18, www.ncbi.nlm.nih.gov/pubmed/28383383.

2. B. D. Smedley, A. Y. Stith, and A. R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, DC: National Academies Press, 2003), www.ncbi.nlm.nih.gov/pubmed/25032386.

3. J. A. Sabin et al., “Physicians’ Implicit and Explicit Attitudes about Race by MD Race, Ethnicity, and Gender,” Journal of Health Care for the Poor and Underserved 20 (2009): 896–913, www.ncbi.nlm.nih.gov/pubmed/19648715.

4. A. R. Green et al., “Implicit Bias among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients,” Journal of General Internal Medicine 9 (2007): 1231–38, www.ncbi.nlm.nih.gov/pubmed/17594129.

5. M. Alsan et. al., “Does Diversity Matter for Health? Experimental Evidence from Oakland,” National Bureau of Economic Research Working Paper 24787, revised August 2019, http://www.nber.org/papers/w24787.

6. BBC News, “‘Liver Branding’ Surgeon Simon Bramhall Fined £10,000,” January 12, 2018, www.bbc.com/news/uk-england-birmingham-42663518.

7. Debra Roter and Judith Hall, Doctors Talking with Patients/Patients Talking with Doctors: Improving Communication in Medical Visits (Westport, CT: Praeger, 2006), 67–68.

CHAPTER ELEVEN: I’LL SEE YOU IN COURT

1. T. Halwani and M. Takrouri, “Medical Laws and Ethics of Babylon as Read in Hammurabi’s Code,” Internet Journal of Law, Healthcare, and Ethics 4, no. 2 (2006), ispub.com/IJLHE/4/2/10352.

2. D. P. Kessler, “Evaluating the Medical Malpractice System and Options for Reform,” Journal of Economic Perspectives 25 (2011): 93–110, www.ncbi.nlm.nih.gov/pubmed/21595327.

3. Carol Peckham, “Medscape Malpractice Report 2015: Why Most Doctors Get Sued,” Medscape, December 9, 2015, www.medscape.com/features/slideshow/public/malpractice-report-2015.

4. I. M. Pellino et al., “Consequences of Defensive Medicine, Second Victims, and Clinical-Judicial Syndrome on Surgeons’ Medical Practice and on Health Service,” Updates in Surgery 67 (2015): 331–37, www.ncbi.nlm.nih.gov/m/pubmed/26650202.

5. D. M. Studdert et al., “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation,” New England Journal of Medicine 354 (2006): 2024–33, www.ncbi.nlm.nih.gov/pubmed/16687715.

CHAPTER TWELVE: IS THERE A BETTER WAY?

1. M. M. Mello et al., “Administrative Compensation for Medical Injuries: Lessons from Three Foreign Systems,” Commonwealth Fund Issue Brief 14 (2011): 1–18, www.ncbi.nlm.nih.gov/pubmed/21770079.

2. Olga Pierce and Marshall Allen, “How Denmark Dumped Medical Malpractice and Improved Patient Safety,” ProPublica, December 31, 2015, www.propublica.org/article/how-denmark-dumped-medical-malpractice-and-improved-patient-safety.

3. Lisa Belkin, “How Can We Save the Next Victim?,” New York Times, June 15, 1997, www.nytimes.com/1997/06/15/magazine/how-can-we-save-the-next-victim.html.

4. BusinessWire, “Global Dental Floss Market Driven by the Increasing Adoption of Preventive Oral Healthcare Measures, Reports Technavio,” April 26, 2017, www.businesswire.com/news/home/20170426006407/en/Global-Dental-Floss-Market-Driven-Increasing-Adoption; Hoosier Econ, “How Much Do Americans Spend on Tattoos?,” May 11, 2015, hoosierecon.com/2015/05/11/how-much-do-americans-spend-on-tattoos.

5. P. A. Offit, “Why Are Pharmaceutical Companies Gradually Abandoning Vaccines?,” Health Affairs 24 (2005): 622–30, www.ncbi.nlm.nih.gov/pubmed/15886152.

6. M. M. Mello et al., “‘Health Courts’ and Accountability for Patient Safety,” Milbank Quarterly 84 (2006): 459–92, www.ncbi.nlm.nih.gov/pubmed/16953807.

7. A. Bolton, “Dems Take a Second Look at GOP Proposals, including Tort Reform,” Hill, February 27, 2010, thehill.com/homenews/house/84021-democrats-take-a-second-look-at-gop-proposals-including-tort-reform.

8. M. M. Mello and A. Kachalia, Evaluation of Options for Medical Malpractice Reform, report to the Medicare Payment Advisory Commission (MedPAC), April 2010, http://www.medpac.gov/docs/default-source/reports/dec16_medicalmalpractice_medpac_contractor.pdf.

CHAPTER THIRTEEN: LOOKING FOR ANSWERS

1. A. C. Mastroianni et al., “The Flaws in State ‘Apology’ and ‘Disclosure’ Laws Dilute Their Intended Impact on Malpractice Suits,” Health Affairs 29 (2010): 1611–19, www.ncbi.nlm.nih.gov/pubmed/20820016.

2. A. Kachalia et al., “Effects of a Communication-and-Resolution Program on Hospitals’ Malpractice Claims and Costs,” Health Affairs 37 (2018): 1836–44, www.ncbi.nlm.nih.gov/pubmed/30395501.

CHAPTER FOURTEEN: BRINGING ALONG OUR BRAINS

1. I. E. Dror, “A Novel Approach to Minimize Error in the Medical Domain: Cognitive Neuroscientific Insights into Training,” Medical Teacher 33 (2011): 34–38, www.ncbi.nlm.nih.gov/pubmed/21067318.

2. B. Zendejas et al., “Patient Outcomes in Simulation-Based Medical Education: A Systematic Review,” Journal of General Internal Medicine 28 (2013): 1078–89, www.ncbi.nlm.nih.gov/pubmed/23595919.

3. J. B. Rousek and M.S. Hallbeck, “Improving Medication Management through the Redesign of the Hospital Code Cart Medication Drawer,” Human Factors 53 (2011): 626–36, www.ncbi.nlm.nih.gov/pubmed/22235525.

CHAPTER FIFTEEN: THE RECKONING

1. E. S. Berner and M. L. Graber, “Overconfidence as a Cause of Diagnostic Error in Medicine,” American Journal of Medicine 121 (2008): S2–S23, www.ncbi.nlm.nih.gov/pubmed/18440350.

CHAPTER SEVENTEEN: GETTING IT RIGHT

1. J. Arimura et al., “Neonatal Heparin Overdose—A Multidisciplinary Team Approach to Medication Error Prevention,” Journal of Pediatric Pharmacology and Therapeutics 13 (2008): 96–98, www.ncbi.nlm.nih.gov/pubmed/23055872.

2. C. P. Thirukumaran et al., “Impact of Medicare’s Nonpayment Program on Hospital-Acquired Conditions,” Medical Care 55 (2017): 447–55, www.ncbi.nlm.nih.gov/pubmed/27922910.

3. S. G. Murray et al., “Using Spatial and Temporal Mapping to Identify Nosocomial Disease Transmission of Clostridium difficile,” JAMA Internal Medicine 177 (2017): 1863–65, www.ncbi.nlm.nih.gov/pubmed/29059280.

4. D. Classen et al., “An Electronic Health Record-Based Real-Time Analytics Program for Patient Safety Surveillance and Improvement,” Health Affairs 37 (2018): 1805–12, www.ncbi.nlm.nih.gov/pubmed/30395491.

5. Eric Topol, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again (New York: Basic Books, 2019).

6. NBC News, “Nurse’s Suicide Highlights Twin Tragedies of Medical Errors,” June 27, 2011, http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors.

7. C. P. Landrigan et al., “Temporal Trends in Rates of Patient Harm Resulting from Medical Care,” New England Journal of Medicine 363 (2010): 2124–34, www.ncbi.nlm.nih.gov/pubmed/21105794.