Do No Harm Project Toolkit

The Do No Harm Project uses clinical vignettes written by trainees to improve recognition of the harms that can result from medical overuse. In an era of increasingly depersonalized health care, the Do No Harm Project promotes the importance of thoughtful, individualized care tailored to the patient.
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Implementation Guide

Case Examples

Clinical vignettes should describe 1) seemingly reasonable though unnecessary care resulting in harm or harm that was narrowly avoided; or 2) misdiagnosis of patient preferences that subsequently led to unnecessary care and harm, or harm that was narrowly avoided. These vignettes do not have to be particularly unusual cases and the harms do not have to be extraordinary, but they should be well researched and thoughtfully written. Instances of medical errors or obvious malpractice should be avoided.

Some examples:

  • CT pulmonary angiography in a low risk patient with negative d-dimer and resultant incidental findings and unnecessary radiation
  • Tight glycemic control in an elderly patient (A1C < 7) results in hypoglycemia, fall and hospitalization
  • Pre-op chest x-ray in an asymptomatic patient leads to incidental benign findings, cancellation of surgery for painful hernia
  • Other examples where harm can result from overuse have been reported as part of the Choosing Wisely Campaign and can be found here: http://www.choosingwisely.org/doctor-patient-lists/

 

Vignette Guidelines

Authors: 3 or fewer. The first author must be a trainee (professional student, intern, resident, fellow, master’s or doctoral student, or post-doctoral student).

Format: Suggested length is 600 words, and not more than 800 words (excluding references). Submissions should include a clinical vignette, which provides an engaging story with pertinent clinical and historical findings. Also, vignettes must include a succinct summary of the clinical issues describing the evidence for medical overuse and suggesting an alternative approach going forward.

Patient consent is required for publication in JAMA Internal Medicine’s Teachable Moments Series, though is not viewed as mandatory so long as cases are fully de-identified.

Click here for patient consent form.

References: 5 or fewer.

 

Getting Started

We suggest that a local Do No Harm Project champion identify a clinical rotation or other venue where time is available to engage trainees on the topics of medical overuse/high value care and encourage submission of clinical vignettes. Ideally, trainees who participate in this program will have dedicated time to write their vignette in order to ensure adequate time for reflection and a resultant high quality product. Local champions such as chief residents or faculty can review proposed cases – e.g. the “one liner” – to be sure they are appropriate instances of “reasonable overuse.” At any point along the way, champions are encouraged to provide final edits, offer suggestions for additional citations, and facilitate publication in JAMA Internal Medicine’s Teachable Moments series. If a writing day is provided for participants, we suggest that a draft be turned in by the end of the writing day. Please see a suggested basic structure for The Do No Harm Project below:

 

Email notification 2 weeks prior to rotation
Housestaff reflect on case of harm from overuse
10 minute “pitch” about the problem of overuse and opportunity to participate in project
Interested housestaff send basic description to project champion(s)
Appropriate cases approved for writing day
References and tips for writing case provided by champion(s)
First draft due by end of writing day
Revisions made by faculty; final draft due within 30 days
Final draft posted online, participant entered into competition, encouraged to submit for publication

 

Click here for suggested email pitches to trainees

 

Suggested selection criteria for local competitions:

Vignettes should be judged on the following criteria:

  • Is the vignette engaging and well written? To what extent are the ideas presented in a logical and interesting manner?
  • Does the vignette address a meaningful aspect of medical overuse? Does the vignette describe harm or near harm caused by medical overuse? Does the vignette focus on activities that are commonly performed and seem acceptable rather than errors or obvious malpractice?
  • To what extent does the vignette advance right care? What is the potential for the alternative approach included in the clinical summary to improve quality of care and patient experience?

Prizes may be offered for the best vignettes to encourage participation. Suggested prizes:

  • Books:
    • Less Medicine, More Health, by H. Gilbert Welch, MD, MPH
    • Overtreated, by Shannon Brownlee
    • The American Health Care Paradox, by Elizabeth Bradley and Lauren Taylor
    • The Lost Art of Healing by Bernard Lown, MD
    • Overdiagnosed. Making People Sick in the Pursuit of Health by H. Gilbert Welch, MD, MPH
    • Gift certificates:
      • Amazon gift cars
      • Food gift cards
      • Other prizes:
        • Certificates
        • Recognition during convocations, meetings, or similar