When medical care leads to harm—difficulty finding words: a teachable moment.

Erin Chamberlain; Matt DiVeronica; Renee Segura

Commentary

When medical care leads to harm—difficulty finding words: a teachable moment.

June 17, 2015

Chamberlain E, DiVeronica M, Segura R. JAMA Intern Med. 2015;175(8):1271-1272.

View more articles from the same authors.

To illustrate the potential for harm associated with overuse of medical care, this commentary describes an incident involving a patient who received unnecessary diagnostic imaging which resulted in iatrogenic harm. A previous AHRQ WebM&M perspective explored medical care overuse as a patient safety problem.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable moment.

May 3, 2017

Deferral of care for serious non-COVID-19 conditions: a hidden harm of COVID-19.

November 18, 2020

Clinicians' expectations of the benefits and harms of treatments, screening, and tests: a systematic review.

February 1, 2017

Medical overuse as a physician cognitive error: looking under the hood.

December 12, 2018

Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States.

December 19, 2018

The evolution of procedural competency in internal medicine training.

November 1, 2017

Electronic health record interoperability-why electronically discontinued medications are still dispensed.

September 22, 2021

Measuring hospital-acquired complications associated with low-value care.

March 6, 2019

Failure to engage hospitalized elderly patients and their families in advance care planning.

April 10, 2013

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

August 11, 2021

Patient mortality during unannounced accreditation surveys at US hospitals.

April 5, 2017

Racial disparities in pain management of children with appendicitis in emergency departments.

September 15, 2015

Addressing the opioid epidemic in the United States: lessons from the Department of Veterans Affairs.

April 5, 2017

Accuracy of practitioner estimates of probability of diagnosis before and after testing.

May 5, 2021

Assessment of perioperative outcomes among surgeons who operated the night before.

June 8, 2022

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

February 2, 2022

Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19.

June 22, 2022

How health care complexity leads to cooperation and affects the autonomy of health care professionals.

February 6, 2008

2019 update on medical overuse: a review.

September 25, 2019

Trends in adverse event rates in hospitalized patients, 2010-2019.

July 27, 2022

US emergency department visits attributed to medication harms, 2017-2019.

October 20, 2021

More than words: patients' views on apology and disclosure when things go wrong in cancer care.

August 24, 2011

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

August 10, 2022

Painting a picture of nurse presenteeism: a multi-country integrative review.

July 22, 2020

Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study

February 12, 2020

To err is human, to apologize is hard.

August 4, 2021

Another medical malpractice crisis?: Try something different.

October 14, 2020

Program access, depressive symptoms, and medical errors among resident physicians with disability.

January 12, 2022

Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation.

November 30, 2022

Improving medication reconciliation in hospitals.

August 31, 2022

Diagnostic excellence through the lens of patient-centeredness.

December 8, 2021

Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical center.

October 21, 2020

Association of opioid consumption profiles after hospitalization with risk of adverse health care events.

June 2, 2021

Association of interruptions with an increased risk and severity of medication administration errors.

May 5, 2010

Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial.

October 6, 2021

When COVID-19 hit, many elderly were left to die.

August 19, 2020

Wrong-site surgery.

December 13, 2017

Cognitive testing of older clinicians prior to recredentialing.

February 5, 2020

Policies to promote shared responsibility for safer electronic health records.

September 29, 2021

Making electronic health records both SAFER and SMARTER.

July 27, 2022

The burden of opioid-related mortality in the United States.

July 18, 2018

Assessing frequency and risk of weight entry errors in pediatrics.

February 15, 2017

Rates of serious surgical errors in California and plans to prevent recurrence.

May 19, 2021

Cognitive bias and public health policy during the COVID-19 pandemic.

July 22, 2020

Effectiveness and efficiency of root cause analysis in medicine.

February 27, 2008

Parent-reported errors and adverse events in hospitalized children.

March 16, 2016

Long-term risk of overdose or mental health crisis after opioid dose tapering.

July 13, 2022

Quality and safety outcomes of a hospital merger following a full integration at a safety net hospital.

March 16, 2022

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Physician use of stigmatizing language in patient medical records.

July 28, 2021

Association of hospital public quality reporting with electronic health record medication safety performance.

October 6, 2021

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

March 7, 2012

Comparison of methods to reduce bias from clinical prediction models of postpartum depression.

May 12, 2021

Hospital-acquired SARS-CoV-2 infection: lessons for public health.

December 9, 2020

An evolving hospital quality star rating system from CMS: aligning the stars.

May 26, 2021

Rapid response teams as a patient safety practice for failure to rescue.

July 7, 2021

Safety culture as a patient safety practice for alarm fatigue.

October 13, 2021

Multilevel factors associated with time to biopsy after abnormal screening mammography results by race and ethnicity.

July 6, 2022

The emotional fallout from the culture of blame and shame.

October 18, 2017

Do words matter? Stigmatizing language and the transmission of bias in the medical record.

January 26, 2018

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Association of patient and family reports of hospital safety climate with language proficiency in the US.

June 29, 2022

Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.

May 19, 2021

Experiences and perspectives of transgender youths in accessing health care: a systematic review.

August 4, 2021

Remote patient monitoring during COVID-19: an unexpected patient safety benefit.

March 23, 2022

Association of past and future paid medical malpractice claims.

March 1, 2023

Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients with acute noncancer pain: a cluster randomized clinical trial.

September 7, 2022

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

May 25, 2022

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Effect of pharmacist email alerts on concurrent prescribing of opioids and benzodiazepines by prescribers and primary care managers: a randomized clinical trial.

October 26, 2022

Racial disparities in child abuse medicine.

November 3, 2021

Nonopioid directives: unintended consequences in the operating room.

June 29, 2022

Characteristics of disease-specific and generic diagnostic pitfalls: a qualitative study.

February 9, 2022

Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.

November 11, 2020

Educational levels of hospital nurses and surgical patient mortality.

April 3, 2005

Health care-associated infections among critically ill children in the US, 2013-2018.

October 28, 2020

Guidance for health care leaders during the recovery stage of the COVID-19 pandemic: a consensus statement.

July 28, 2021

Association of inappropriate outpatient pediatric antibiotic prescriptions with adverse drug events and health care expenditures.

June 8, 2022

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Racial and ethnic differences in emergency department pain management of children with fractures.

April 22, 2020

Race as a social construct in psychiatry research and practice.

December 22, 2021

The spectrum of harm associated with modern medicine.

April 6, 2022

Ventilator-associated pneumonia—the wrong quality measure for benchmarking.

January 2, 2008

Effect of a mobile app on prehospital medication errors during simulated pediatric resuscitation: a randomized clinical trial.

September 15, 2021

Adverse events and hospital-acquired conditions associated with potential low-value care in Medicare beneficiaries.

August 11, 2021

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.

April 15, 2020

Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.

March 2, 2022

Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.

January 4, 2021

Prescribing decision making by medical residents on night shifts: a qualitative study.

November 9, 2022

Nonfatal opioid overdoses at an urban emergency department during the COVID-19 pandemic.

October 7, 2020

Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.

August 25, 2021

When bad things happen: training medical students to anticipate the aftermath of medical errors.

September 2, 2020

Emotional exhaustion among US health care workers before and during the COVID-19 pandemic, 2019-2021.

October 5, 2022

Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting.

January 8, 2020

A new category of "never events"-ending harmful hospital policies.

November 9, 2022

Medication use leading to emergency department visits for adverse drug events in older adults.

December 19, 2007

Clinical features and preventability of delayed diagnosis of pediatric appendicitis.

September 29, 2021

Teamwork in Healthcare.

September 23, 2015

Related Resources

Hospital Harm Project.

October 31, 2023

Patient Safety Innovations

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

August 30, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy.

October 26, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan.

December 4, 2019

Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety.

August 21, 2019

Intravenous infusion administration: a comparative study of practices and errors between the United States and England and their implications for patient safety.

July 10, 2019

Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.

June 19, 2019

In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States.

March 13, 2019

Medicine Safety: Take Care.

February 27, 2019

Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.

January 30, 2019

Active-shooter response at a health care facility.

September 19, 2018

Technical rationality and the decentring of patients and care delivery: a critique of 'unavoidable' in the context of patient harm.

July 25, 2018

A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.

July 11, 2018

A piece of my mind. The art of constructive worrying.

June 20, 2018

Disruptive physician behavior: the importance of recognition and intervention and its impact on patient safety.

May 16, 2018

Matt's story: learning from heartbreak.

May 9, 2018

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

Latent risk assessment tool for health care leaders.

April 25, 2018

Diagnostic performance dashboards: tracking diagnostic errors using big data.

April 4, 2018

Our other prescription drug problem.

March 14, 2018

Diagnosing crime and diagnosing disease—part 1 and part 2.

February 28, 2018

Supporting second victims.

February 21, 2018

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.

February 21, 2018

Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.

February 14, 2018

Technological distractions—part 1 and part 2.

February 14, 2018

To care is human—collectively confronting the clinician-burnout crisis.

February 7, 2018

Strategies to reduce patient harm from infusion-associated medication errors: a scoping review.

January 31, 2018

Safety analysis over time: seven major changes to adverse event investigation.

January 24, 2018

See More About The Topic

Hospitals

Health Care Providers

Medicine

Epidemiology of Errors and Adverse Events

Error Analysis

When medical care leads to harm—difficulty finding words: a teachable moment.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

When medical care leads to harm—difficulty finding words: a teachable moment.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site