Doctors’ Secrets for Protecting Yourself from Preventable Harm

Updated 2026 edition by Steve Wolf
With Stephanie Sea, M.D., and doctors and nurses speaking anonymously

Copyright 2012, 2013, 2026 Steve Wolf. All rights reserved.

This book is a practical patient-safety field guide. It is not a substitute for diagnosis, treatment, emergency care, legal advice, or the judgment of a qualified clinician who has examined the patient. If symptoms suggest an emergency, call emergency medical services immediately.

Reviews

“This is a book everyone should read before they end up in the hospital.”
—Dr. Mary Ann Block, D.O., physician and author

“When I have a family member in the hospital, I want to be there. When I can’t be there, I want someone who’s read this book to be there.”
—Shelley Larson, R.N., acute-care nurse

“It is easy to forget how dangerous hospitals are for patients. This book is a concise and valuable field guide for steering clear of the most common dangers.”
—Dr. Matthew Plotkin, M.D.

Contents

Dedication

This book is dedicated in memory of my friend Ray Chapman.

Ray undoubtedly saved the lives of thousands of servicemen, police officers, FBI agents, and members of special operations teams by teaching the remarkable survival-shooting skills that he developed and perfected. He won more than 250 international shooting competitions, including the World Championship of Practical Shooting. He stressed shot placement, rapid movement, and the use of cover.

He was also among the kindest and most genuine people I have known, never forgetting to live as an example of what it meant to be a friend and a gentleman.

Yet what no Japanese gunner in World War II could accomplish, and what no Korean infantryman achieved, was done by the ordinary failure of a health-care system. Following a minor fall while working in his garden, Ray was brought to the hospital. Procedural shortcomings allowed infection to flourish, and a clerical error changed medication dosages. What should have been a brief emergency-room visit became months of terminal suffering.

Dead is dead, regardless of the cause. Learning, understanding, managing, and minimizing the risks posed by hospitals is every bit as important as knowing how to handle visible dangers. It is the sincere hope of everyone who contributed to this book that lives will be saved with this information.

About This Updated Edition

If you are in a hospital, or if someone you love is in a hospital, read this book immediately. If not, keep it where you can find it quickly. Hospitalization often arrives without warning, and the person most affected is frequently the least able to supervise what is happening.

This book remains short, direct, and practical by design. The central rule has not changed: never be hospitalized alone if there is any safe and lawful alternative. A competent advocate at the bedside can notice the wrong pill, the unwashed hands, the empty IV bag, the unanswered call light, the missing test result, the wrong chart, the premature discharge instruction, and the vague explanation that needs a second question.

What has changed since the first edition is the scale and precision of patient-safety evidence. The World Health Organization now summarizes the global problem bluntly: around 1 in 10 patients is harmed in health care, more than 3 million deaths occur annually due to unsafe care, more than 50 percent of patient harm is preventable, and medication-related harm accounts for about half of avoidable harm.1 A modern review of inpatient care at 11 Massachusetts hospitals found at least one adverse event in 23.6 percent of admissions, with 6.8 percent of admissions involving a preventable adverse event.2

Older editions of this book used a “fifth leading cause of death” framing. That warning captured the seriousness of preventable medical harm, but rankings vary by methodology and year. The safer 2026 statement is this: preventable harm in health care remains a major source of death, disability, and avoidable suffering, and patients can reduce risk by becoming active participants in care.1

Those numbers do not mean that doctors and nurses are villains. The people who work in hospitals usually want patients to live, heal, and go home. The problem is that hospitals are complex, overloaded systems in which exhausted, interrupted humans use complicated technology, incomplete records, rotating shifts, look-alike packages, sound-alike drug names, hidden infections, and time pressure to care for fragile people. Good intentions are not enough. Systems fail. People miss things. Patients and advocates can catch some of those failures before they become permanent.

This updated edition adds current advice on the Joint Commission’s 2026 National Performance Goals, diagnostic error, medication reconciliation, electronic records, patient portals, sepsis, hand hygiene, pressure injuries, falls, blood-clot prevention, discharge planning, and family engagement.3 5

A Hospital Is No Place for a Sick Person

Do not blindly assume that a doctor, nurse, aide, technician, pharmacist, surgeon, or computer system knows best at every moment. Hospital personnel often know a great deal, but they may not know you. They may not know that a home medication was changed last week, that a previous anesthetic caused a dangerous reaction, that you are allergic to an adhesive, that your usual weight was entered in pounds where kilograms were expected, or that the person in the next bed has a similar name.

AHRQ’s patient-safety definitions make the point clearly. An adverse event is harm from medical care rather than from the underlying disease; a preventable adverse event is harm caused by an error or by failure to apply an accepted prevention strategy.7 In plain language, a patient can be hurt not because illness was unavoidable, but because a preventable step was missed.

The most important safety device in the room is not a monitor. It is an alert human being who knows the patient, watches the process, takes notes, asks questions, and politely refuses to be brushed aside. Hospitals increasingly recognize patient and family engagement as a safety intervention. AHRQ identifies better communication from admission, bedside shift reports, and discharge planning throughout the stay as core strategies for safer care.4

Never be hospitalized alone. If possible, arrange a rotating team of family members, friends, or hired advocates. If the patient is too ill, sedated, confused, or overwhelmed to participate, the advocate becomes the patient’s external memory and second set of eyes. The advocate should not obstruct care, argue for sport, or practice internet medicine. The advocate’s job is to observe, document, clarify, verify, and escalate respectfully when something does not make sense.

The right attitude is firm, calm, and collaborative. Say, “I know everyone is busy, and I appreciate what you are doing. I need to verify this before it happens.” That sentence can save a life.

Infection

Health-care-associated infections remain one of the clearest reasons to take hospital safety personally. CDC reports that, on any given day, about 1 in 31 U.S. hospital patients has at least one health-care-associated infection.8 CDC’s 2024 progress report, posted in January 2026, showed improvement in several acute-care hospital measures compared with 2023, including decreases in central-line associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, hospital-onset MRSA bacteremia, and hospital-onset C. difficile, but improvement is not the same as elimination.8

The practical lesson is simple: hospitals contain sick people, invasive devices, shared surfaces, hurried staff, and organisms that may be resistant to common treatment. Your room may look clean and still contain pathogens on the bed rail, call button, phone, remote control, rolling table, chair arms, IV pole, faucet handle, doorknob, stethoscope, keyboard, or clinician’s clothing.

You have the right to ask anyone who touches you to clean their hands. CDC specifically tells patients and loved ones that they can remind health-care personnel to clean their hands and offers language such as, “Before you start the exam, would you mind cleaning your hands again?”9 Use that language. If you are embarrassed, remember that embarrassment is not sterile.

Alcohol-based hand sanitizer is preferred in most clinical situations unless hands are visibly soiled, in which case soap and water are needed.10 Patients and visitors should clean their own hands before eating, before touching eyes, nose, or mouth, before and after changing dressings, after using the bathroom, after coughing or sneezing, and after touching hospital surfaces.9

Wipe high-contact surfaces if hospital policy permits it. Ask staff to disinfect shared equipment before it touches you. If a stethoscope comes out of a pocket, ask that it be cleaned. If a phone, pen, tablet, or consent stylus passes from hand to hand, assume it needs cleaning.

Pay special attention to invasive devices. Central lines, urinary catheters, feeding tubes, drains, IVs, and ventilator equipment can be lifesaving, but every device is also a pathway for infection, misconnection, or injury. Ask daily, “Does this line, catheter, drain, or tube still need to be in?” The safest unnecessary device is the one that has been removed.

Sepsis deserves special emphasis. CDC describes sepsis as the body’s extreme response to infection and a life-threatening medical emergency.11 CDC’s 2026 sepsis information states that at least 1.7 million U.S. adults and more than 18,000 children develop sepsis each year, and that at least 350,000 adults and more than 1,800 children who develop sepsis die during hospitalization or are discharged to hospice.11 Warning signs include clammy or sweaty skin, confusion or disorientation, extreme pain or discomfort, fever, shivering or feeling very cold, high heart rate or weak pulse, and shortness of breath.11 If an infection is getting worse or the patient suddenly seems dramatically sicker, ask directly, “Could this be sepsis?” Do not wait politely while a life-threatening infection accelerates.

You don't have to wait for staff to notice. Many hospitals let a patient or a family member summon a rapid response team directly when they believe something is seriously wrong and they aren't being heard. This is sometimes called Condition H, short for Condition Help. On admission, ask whether the hospital has a patient-and-family-activated rapid response system and how to call it. The number is often posted in the room or written on the whiteboard; keep it where you can reach it.

Medication

Medication harm is one of the most common forms of preventable hospital injury. The WHO states that half of avoidable health-care harm is medication-related.1 The modern Massachusetts inpatient study found adverse drug events to be the largest category of adverse events, accounting for 39 percent of adverse events detected.2

The first defense is an accurate medication list. AHRQ’s medication-reconciliation guidance emphasizes a single shared list, a “One Source of Truth,” used by all disciplines to document the patient’s current medications.12 Do not rely on memory. Bring the actual prescription bottles when possible, including inhalers, injections, creams, eye drops, patches, and over-the-counter products. Bring supplements, vitamins, herbs, cannabis products, recreational substances, and a written list of allergies and prior adverse reactions.

Every medication list should answer five questions: what the drug is, why it is taken, the dose, the schedule, and what changed. Many hospital errors arise because a medication was stopped unintentionally, continued when it should have been stopped, restarted at the wrong dose, duplicated under a different name, or mixed with another drug that changed its effect.

If your doctor verbally changed a dose, make sure the prescription and record were updated. A bottle that says 100 mg can become dangerous if you were told to take half a tablet but the hospital record still says 100 mg. The record wins unless someone corrects it.

Weight matters. Many hospital drug doses are calculated in kilograms. One pound equals 0.453592 kilograms. A 100-pound patient weighs about 45.4 kg; a 200-pound patient weighs about 90.7 kg. If pounds are accidentally entered as kilograms, a patient may receive more than double the intended dose. Ask what weight is in the chart and whether it is in pounds or kilograms.

Before accepting any medication, ask: “What is this, what is it for, what dose is it, and does it match my chart?” If a pill looks different from what you normally take, do not swallow first and ask later. There may be a valid reason, such as a hospital formulary substitution, but the reason should be explainable before the medicine is taken.

The Joint Commission reminds patients that medication safety is a team effort involving the patient, doctor, pharmacist, and caregivers, and that patients should ask questions about new medications and speak up if something does not sound right.13 In 2026, Joint Commission hospital programs have transitioned from the old National Patient Safety Goals label to National Performance Goals, but the bedside principle is unchanged: identification, medication safety, infection prevention, and patient participation remain core safety themes.3

Be especially vigilant with high-alert medications: anticoagulants, insulin, opioids, sedatives, concentrated electrolytes, chemotherapy, IV antibiotics, and any medicine that affects breathing, bleeding, blood pressure, or blood sugar. These drugs can be appropriate and lifesaving, but they deserve an extra verification loop.

Be cautious about miracle cures, supplement schemes, and treatments marketed to desperate patients. Some complementary measures, such as relaxation techniques, massage for comfort, or guided imagery, may support well-being when used safely alongside medical care. But any product that promises a guaranteed cure, requires secrecy from your doctor, or asks you to abandon evidence-based treatment should be treated as a threat.

Communication

Communication is not a courtesy feature of medicine. It is a safety system. A patient who cannot tell the story clearly, a doctor who is interrupted, a nurse who receives a rushed handoff, or a discharge planner who assumes the family understands can create the conditions for harm.

AHRQ’s diagnostic-safety toolkit says one in three patients will experience a diagnostic error firsthand and that communication breakdowns during the patient-provider encounter are a leading contributor.14 The toolkit encourages patients to “Be the Expert on You” by telling their health story clearly and concisely, and encourages clinicians to listen without interruption at the start of an encounter.14

Before a clinician enters, write down the three things that matter most: what changed, what worries you, and what question must be answered before the conversation ends. Do not let the visit end with the central concern untouched. If the clinician begins to leave, say, “Before you go, I need to ask the question I wrote down.”

Use closed-loop communication. After you receive instructions, repeat them back in your own words: “Let me make sure I understand. You want me to stop the blood thinner tonight, take the antibiotic twice a day with food, and come back if the fever returns.” If you cannot repeat the plan, you do not yet have the plan.

Shift change is a high-risk moment because responsibility moves from one team to another. Ask for bedside shift report when appropriate. At minimum, before the current nurse leaves or soon after the next nurse arrives, verify the plan: current diagnosis, major risks, medications due, tests pending, mobility restrictions, diet, tubes and lines, pain plan, and what would trigger a call to the doctor.

Names matter. Learn the names and roles of the people caring for you. “Dr. Lee, hospitalist,” “Jamie, day nurse,” “Alicia, respiratory therapist,” and “Sam, pharmacist” are more useful than “the woman in blue scrubs.” Being known also humanizes you. Gratitude helps. A calm “thank you” does not make you weak; it makes you memorable.

Discharge communication deserves the same intensity as surgery. Before leaving the hospital, you should understand the diagnosis, what improved, what remains unresolved, which medications changed, which symptoms require emergency care, who to call, and when follow-up must occur. If a test result is pending, get the name of the test, who will review it, and how you will be contacted.

Verification

Verification is the habit of confirming that what is about to happen is intended for the right patient, at the right time, in the right way. It is not paranoia. It is standard safety behavior borrowed from aviation, firefighting, engineering, and surgery.

Read the hospital bracelet. Confirm the spelling of the name, date of birth, allergies, and any warnings. Staff should use at least two patient identifiers before medication, blood draws, procedures, imaging, transport, and transfusion. Do not answer only “yes” to a name spoken at you. State your name and date of birth.

Before any procedure, ask the clinician to describe what will be done and why. If you are being transported, ask where you are going and what test or procedure is planned. If the answer does not match what you were told, stop the process until it is clarified.

Tube tracing matters. When a patient has multiple tubes, lines, drains, and catheters, misconnections can be catastrophic. Ask staff to trace a tube from the patient to its source before connecting, injecting, or changing anything. This is especially important around IV lines, feeding tubes, oxygen, drains, catheters, and epidural lines.

Verify fluids. IV bags should not run dry without notice, pumps should not alarm endlessly, and the label on the bag should match the order. If a new bag appears, ask what it is. If a pump alarm persists, call for help.

Prevent pressure injuries. The WHO identifies pressure ulcers among major avoidable harms, and AHRQ’s pressure-ulcer toolkit notes that more than 2.5 million people in the United States develop pressure ulcers each year.1 Immobile patients need repositioning. Ask for the repositioning plan, skin checks, heel protection, moisture control, nutrition support, and pressure-relieving surfaces when needed. Do not accept “we will get to it” as the entire plan if the patient is unable to move independently.

Fall prevention is verification too. AHRQ PSNet reports that approximately 700,000 to 1 million U.S. hospital patients fall each year and describes falls as the most common preventable adverse event within hospitals.16 CDC’s STEADI inpatient guidance emphasizes that older adults are more likely to fall in the first month after discharge after a hospital stay.17 Confirm whether the patient may get out of bed alone. If not, use the call light before standing. Skid-resistant footwear, cleared pathways, proper lighting, bed alarms when indicated, and a documented personalized fall plan reduce risk.

Doctors and Hospitals

Choosing the doctor and hospital can affect risk. When you have time and choice, choose facilities and clinicians experienced with the condition or procedure. High volume does not guarantee excellence, but repeated experience with a specific operation, complication, or disease process can matter.

Use current public tools. Medicare Care Compare allows patients to find and compare hospitals, doctors, nursing homes, hospice, home health, inpatient rehabilitation, long-term care hospitals, dialysis facilities, and other Medicare-approved providers using federal quality data.18 The Leapfrog Hospital Safety Grade assigns letter grades from A to F to general hospitals based on how well they protect patients from errors, accidents, injuries, and infections, and it's free to look up. State medical boards can confirm licensure and disciplinary actions. Hospital websites may list accreditations, specialty programs, infection metrics, and patient-safety resources.

Ask direct questions. How many times have you performed this procedure? What are your complication rates? What alternatives should I consider? What happens if I do nothing today? Who covers for you at night and on weekends? If a complication occurs, which hospital would treat it? If you were advising your own family member, what would you do differently?

Be alert to conflicts and incentives. Some procedures are overused. Some tests are done because they are easier to order than to explain. Some clinicians are excellent at one thing and overly eager to apply it to everyone. A second opinion is not an insult. It is a normal safety practice when the stakes are high, the diagnosis is uncertain, the procedure is elective, or the proposed treatment carries permanent consequences.

If something feels wrong, ask other professionals carefully and respectfully. Nurses, pharmacists, therapists, and technicians often know which clinicians are meticulous, rushed, responsive, dismissive, or difficult to reach. Do not ask for gossip. Ask, “Is there anything you would want your own family to know before proceeding?”

Records

Records are the memory of the hospital. If the record is wrong, the treatment can be wrong. Electronic health records reduce some handwriting and interaction errors, but they introduce new problems: copy-and-paste errors, outdated medication lists, wrong-click orders, duplicate charts, portal delays, and information buried in the wrong tab.

Keep your own log. Record the date, time, medication, dose, test, procedure, symptom, name of staff member, and unanswered question. A notebook is fine. A phone note is fine. A shared document with family can work well. The point is not to create a perfect legal record; it is to create a reliable bedside memory.

Use the patient portal when available. Portals can show test results, medication lists, discharge instructions, visit summaries, and messages. However, do not assume every important result appears instantly or that a normal-looking portal means everything is settled. Ask who is responsible for reviewing each pending result.

When copying or transferring records, confirm completeness. Missing pages, reversed order, omitted medication lists, absent imaging disks, and incomplete discharge summaries can create dangerous confusion. If you are transferred to another facility, send allergies, medication list, diagnosis, recent vitals, procedures, imaging, labs, code status, and the name of the sending physician.

HHS states that the HIPAA Privacy Rule generally gives patients the right to inspect, review, and receive copies of medical and billing records held by covered providers and health plans, with limited exceptions.19 A provider cannot deny a copy because a bill has not been paid; the provider may charge reasonable copying and mailing costs, but may not charge a search or retrieval fee.19 If the record is inaccurate or incomplete, patients may request amendment, and if the provider disagrees, the patient generally has the right to submit a statement of disagreement for the record.19

Test-result follow-up is a major safety issue. AHRQ PSNet identifies failure to follow up test results and unreliable outpatient triage as systems contributors to diagnostic error.20 Do not accept “no news is good news.” No news may mean no one looked.

Scheduling and Timing

Emergency symptoms do not wait for a convenient calendar. If someone may be having a stroke, heart attack, sepsis, airway emergency, severe allergic reaction, major bleeding, or other acute threat, call emergency services immediately. Do not delay care because of a statistic about weekends or shift changes.

For elective, postponable procedures, timing can still matter. Ask who will perform the procedure, who will assist, whether trainees will participate, whether the surgeon has another major case immediately before or after yours, and who will be available if problems arise overnight or on the weekend.

The safest scheduling strategy is not superstition. It is to ensure the right team, the right preparation, the right equipment, and the right postoperative monitoring. Morning cases may reduce fasting time and fatigue. Weekday scheduling may improve access to full ancillary services. But a highly prepared team on a Friday is better than an unprepared team on a Tuesday.

Confirm preoperative instructions in writing: when to stop eating and drinking, which medications to take or hold, whether blood thinners require special handling, whether diabetes medications need adjustment, when to arrive, who will drive you home, and what symptoms should cancel or postpone the procedure.

Surgery

Surgical safety begins before the operating room. Make sure you, the surgeon, the anesthesiology team, and the nursing team agree on the exact procedure, the exact site, the reason for surgery, the expected benefit, the alternatives, and the known risks. If the operation involves a side, level, tooth, eye, limb, digit, lesion, or device, verify it repeatedly.

Mark the surgical site with the surgeon when appropriate. Do not let the wrong side be marked casually by someone who has not reviewed the case. If you are having spine surgery, ask how the surgical level will be confirmed. If imaging is required in the operating room, ask how it will be used.

Anesthesia is a separate safety conversation. Report all prior anesthesia problems, difficult intubation, sleep apnea, loose teeth, implanted devices, allergies, blood thinner use, alcohol or substance use, and family history of malignant hyperthermia or anesthesia complications. Ask how nausea, pain, delirium, airway risk, and medication interactions will be managed.

Before surgery, confirm the plan for infection prevention, blood-clot prevention, pain control, mobility, diet, wound care, and discharge. AHRQ’s hospital-associated venous thromboembolism guide states that pulmonary embolism resulting from deep-vein thrombosis is the most common preventable cause of hospital death and that pharmacologic prevention is safe, effective, cost-effective, and recommended by authoritative guidelines but remains underused.21 Ask whether you need early walking, compression devices, stockings, or anticoagulant medication.

After surgery, ask what findings were discovered, whether the planned procedure changed, what was removed or implanted, what pathology or lab results are pending, and what warning signs require immediate care.

Important Tips

Advance directives matter because there may come a time when the patient cannot speak. A medical power of attorney, health-care proxy, living will, or other advance directive allows a trusted person to make decisions if the patient lacks capacity. Requirements vary by state, so use the correct state form and give copies to the hospital, proxy, primary physician, and relevant family members.

Pick one coordinator. If five relatives call the nurse every hour, important information will scatter. The coordinator should receive updates, keep the log, distribute information to family, and know how to reach the care team.

Spend no more time in the hospital than medically necessary, but do not leave before a safe discharge plan exists. A short admission with chaotic discharge can be more dangerous than one additional day used to reconcile medications, arrange equipment, teach wound care, schedule follow-up, and clarify warning signs.

Ask whether every test or treatment changes management. More medicine is not always better medicine. Every test has false positives, false negatives, incidental findings, cost, radiation or procedural risk, and downstream consequences. The right question is not “Can we test?” but “How will this result change what we do?”

Blood clots are a major preventable risk. Ask for a venous thromboembolism risk assessment, especially after surgery, trauma, cancer treatment, prolonged immobility, pregnancy-related hospitalization, heart failure, severe infection, or prior clot.21

Sleep and orientation protect recovery. Bring glasses, hearing aids, dentures, chargers, and familiar items. Confusion and delirium are more likely when patients are sleep-deprived, infected, dehydrated, overmedicated, isolated, or unable to see and hear. Reorient the patient gently: name, place, date, reason for hospitalization, and what happens next.

Environment

Comfort is not decoration. Calm, light, sound control, temperature, hydration when permitted, clean surfaces, and easy access to the call light support recovery. Learn the bed controls, call button, bathroom route, phone, television, lights, and thermostat. Make sure the patient can reach water if allowed, tissues, glasses, hearing aids, phone, and call light.

Keep the room uncluttered. Clutter interferes with cleaning, increases fall risk, and hides important equipment. Ask visitors to clean their hands, stay home when ill, and keep voices low. If the patient has isolation precautions, follow them exactly.

Natural daylight helps orientation and sleep cycles. Open shades during the day if the patient wants light and it is medically appropriate. Reduce noise and unnecessary waking at night when possible, but do not refuse necessary monitoring.

The room should feel human. A patient who is treated as “the gallbladder in 412” is easier to overlook than a known person with a story, family, and advocate. Put a simple note where allowed: “Steve likes clear explanations and wants medication names repeated.” Small human details can change behavior.

The 75-Point Hospital Safety Checklist

Use this checklist as a field tool. It is deliberately practical. Print it, save it on a phone, or copy it into a bedside notebook.

Helpful Resources

Use reliable sources before random search results. Good starting points include MedlinePlus, Mayo Clinic, CDC, AHRQ, AHRQ PSNet, Medicare Care Compare, and your hospital’s patient portal.

For medication identification, use a pharmacist first. Online pill identifiers can help, but they are not a substitute for professional confirmation when a medication discrepancy could harm the patient.

For diagnostic uncertainty, write a one-page health story: the main symptom, when it started, what changed, what makes it better or worse, relevant history, current medicines, allergies, and the biggest concern. Bring that page to appointments and hospital discussions.

Medication Chart

Also list allergies, prior bad reactions, preferred pharmacy, emergency contact, primary physician, specialists, implanted devices, and advance-directive location.

Patient Rights and Responsibilities

Patients generally have the right to respectful care, understandable information, participation in decisions, privacy, confidentiality, access to records, informed consent, refusal of treatment within legal limits, reasonable continuity of care, interpreter services when needed, and a process for grievances or ethics consultation. The exact wording and legal effect vary by jurisdiction, hospital policy, payer, and care setting, so ask for the hospital’s current patient-rights document at admission.

Patients and families also have responsibilities. Provide accurate information about illness, medications, allergies, prior hospitalizations, insurance, and barriers to following the plan. Ask questions when you do not understand. Give the hospital a copy of any advance directive. Treat staff, other patients, and visitors with reasonable respect. Speak up early when instructions are impossible, unaffordable, unsafe, or unclear.

The best model is partnership. The patient is not a subordinate, prisoner, or passive package moving through an industrial process. The patient is the central participant in the care system.

About the Author

Steve Wolf has spent much of his career challenging death by understanding the physical circumstances that allow it to occur. Experiences as an EMT, rescue diver, and member of sheriff’s emergency-services teams in New Orleans, New York, and Memphis gave him regular opportunities to delay death. As a movie stunt and special-effects coordinator, his job has been to use science to create the illusion of danger while controlling real risk. As a science educator and inventor, he has built systems that turn danger into teachable structure.

In stunt work, professional safety depends on identifying the failure path before the failure occurs. If you do not get shot, you avoid the complications that bullets create. If you keep heat away from skin with proper insulation during a full-body burn, you do not get burned. If you shunt blasting wires while setting pyrotechnics, you reduce the risk of accidental ignition. If you use tempered glass for stunts, you reduce the risk of catastrophic laceration.

The same principle applies in hospitals. If you thwart the conditions that lead to accidental harm, you greatly reduce the odds of becoming the next preventable tragedy. Steve believes that science routinely provides pathways through danger to safety.

Acknowledgements

This book could not have been made without the help of many people. Most spoke openly on condition of anonymity. Others who provided help include Dr. Stephanie Sea, M.D.; Dr. Mary Ann Block, D.O.; Makaira Casey; Danielle Brewer, L.M.T.; Beverly McCord, patient-care expert; Michael Turner; Doug Vogelsass; Elizabeth Wolf, P.A.; and Maegan Wolf, L.M.T.

References

Sources cited throughout this edition, listed in order of first appearance. Each citation in the text links directly to its source.

• World Health Organization, Patient safety fact sheet
• Bates et al., The Safety of Inpatient Health Care, New England Journal of Medicine
• AHRQ, Guide to Patient and Family Engagement in Hospital Quality and Safety
• CDC STEADI, Inpatient Care
• AHRQ PSNet, Adverse Events, Near Misses, and Errors
• CDC, National and State Healthcare-Associated Infections Progress Report
• CDC, About Hand Hygiene for Patients in Healthcare Settings
• CDC, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings
• CDC, About Sepsis
• AHRQ, MATCH Toolkit for Medication Reconciliation
• The Joint Commission, Speak Up: About Your Medications
• The Joint Commission, National Performance Goals and National Patient Safety Goals
• AHRQ, Toolkit for Engaging Patients To Improve Diagnostic Safety
• AHRQ, Preventing Pressure Ulcers in Hospitals
• AHRQ PSNet, The Ongoing Journey to Prevent Patient Falls
• Medicare, Care Compare
• HHS, Your Medical Records
• AHRQ PSNet, Diagnostic Errors
• AHRQ, Preventing Hospital-Associated Venous Thromboembolism
• The Leapfrog Group, Hospital Safety Grade
• AHRQ, Patient and Family Engagement (patient and family-activated rapid response)