Table Of ContentPraise for The Anatomy of Medical Errors
“With unimaginable serenity, Crisp takes us on her Shakespearean
journey with superb skill, startling courage, and searing introspec-
tion. Her nightmare reveals a frightening level of dysfunction in
our increasingly impersonal medical system. In the words of Othello’s
Desdemona: “These are portents; but yet I hope, I hope, They do not
point on me.” Those of us in medicine must not ignore either this
tragedy, or the heroine who survived it.”
–Byers W. Shaw Jr., MD
Professor, Department of Surgery
University of Nebraska Medical Center
“With medical mistakes now our third leading cause of death, I
think it’s wise for people to become somewhat less afraid of disease
and a lot more afraid of treatments.”
–Allen Frances, MD
Chair, DSM IV Task Force
Professor Emeritus & Former Chair
Duke University School of Medicine
Department of Psychiatry and Behavioral Sciences
Author, Saving Normal
“What a masterpiece! Far beyond a litany of errors, this story could
only be written by a nurse who was profoundly betrayed by our health
“care” system and by her “care” givers. By courageously sharing
her personal story, Donna Helen Crisp gently leads all of us back
to our shared humanity. Follow her and you will never be able to
see medicine or nursing through the same lens again. Her wisdom,
observations, and insight are unparalleled and illuminate the path to
healing for both patients and nurses.”
–Kathleen Bartholomew, MN, RN
Author, Speaker, and Educator
“This is a powerful narrative of the ripple effect each caregiver’s
action has on a patient’s experiences and perception of care, as told
through an insider’s lens. The story illustrates the personal experience
of uncertainty, lack of communication, fear, and suffering that can
only be moderated through relationship and honest dialogue between
patient and providers. Anatomy of Medical Errors is essential
reading with ethics discussions for those in the healthcare field as a
tragic case study from the patient’s point of view.”
–Jane S. Braaten, PhD, RN, CNS/ANP, CPPS
Patient Safety Manager/Nurse Scientist
Castle Rock Adventist Hospital and Centura Health
Co-author/co-editor High Reliability Organizations
and
–Cynthia A. Oster, PhD, RN, APRN, MBA, ACNS-BC, ANP
Nurse Scientist, Centura Health
Clinical Nurse Specialist, Porter Adventist Hospital
Co-author/co-editor High Reliability Organizations
“In every nurse’s life, there will come an occasion when that nurse or
a loved one is poorly served by the healthcare system. Donna Helen
Crisp’s courageous and poignant memoir of her own experience has
the potential to stimulate significant discussion about the intersec-
tion of health professionals’ compassion, personal integrity, advocacy
for their patients, and accountability to one’s employer in a complex
healthcare environment. This book is essential reading for all health
professionals.”
–Nancy C. Sharts-Hopko, PhD, RN, FAAN
Professor and Director, PhD Program
College of Nursing, Villanova University
“Having experienced an emotional journey not unlike that shared by
Donna Helen Crisp, I laud her ability to draw her readers into her
tale of medical harm, suffering, denial, forgiveness, and ultimately
hope—hope for more skilled and compassionate care of all who are
ill. Her writing elegantly weaves her remarkable story with evidence
from medical literature and quotes from Shakespeare to evoke anger,
empathy, insight, and hope in her readers. Well done, indeed.”
–John T. James, PhD
Author, A Sea of Broken Hearts
Patient Safety America
“Donna Helen Crisp has taken her shocking experience of medical
harm and substandard care and turned it into important lessons for
us all. Patients, nurses, doctors … everyone should read this book!”
–Helen Haskell, MA
President, Mothers Against Medical Error
“The robust combination of Crisp’s personal story, her professional
experiences, and a glimpse at the research results in this powerful
narrative on medical errors and lack of transparency will help read-
ers advocate for an improved health system with a culture of honesty
and disclosure of medical errors.”
–Kaci Hickox, MSN, MPH, RN
Clinical Nurse Educator and Advocate
Eugene, Oregon
“The whimsical combination of Shakespeare quotes alongside the
very serious topic of medical errors makes for a fascinating journey
into the perils that can exist in healthcare. This story, narrated in
first person, provides insight into the level of integrity, dignity, trans-
parency, compassion, and respect needed to provide competent medical
and nursing care.”
–Brittney Wilson, BSN, RN
Author, Blogger, Influencer, The Nerdy Nurse
“This is a must-read for anyone dedicated to humanizing healthcare.
Donna Helen Crisp’s saga is a compelling read of her near-death
experience in the epicenter of modern medicine. Lessons abound for
doctors, nurses, and everyone looking after the well-being of friends
and relatives.”
–Edward J. Halloran, PhD, RN
Associate Professor (ret.)
University of North Carolina School of Nursing
DONNA HELEN CRISP, JD, MSN, RN, PMHCNS-BC
Copyright © 2017 by Donna Helen Crisp
All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechan-
ical, photocopying, recording, or otherwise, without written permission from the publisher.
Any trademarks, service marks, design rights, or similar rights that are mentioned, used, or
cited in this book are the property of their respective owners. Their use here does not imply
that you may use them for similar or any other purpose.
This book is not intended to be a substitute for the medical advice of a licensed medical
professional. The author and publisher have made every effort to ensure the accuracy of the
information contained within at the time of its publication and shall have no liability or
responsibility to any person or entity regarding any loss or damage incurred, or alleged to
have incurred, directly or indirectly, by the information contained in this book. The author
and publisher make no warranties, express or implied, with respect to its content, and no
warranties may be created or extended by sales representatives or written sales materials.
The author and publisher have no responsibility for the consistency or accuracy of URLs and
content of third-party websites referenced in this book.
This book is a work of nonfiction based on the life and experiences of the author. In some
cases, names of people, places, dates, or sequences or details of events have been changed to
protect the privacy of others. The author has stated to the publisher that, except in such cases,
the contents of this book are true. The opinions expressed by the author and those providing
comments are theirs alone and do not reflect the opinions of Sigma Theta Tau International
or any employee thereof.
The Honor Society of Nursing, Sigma Theta Tau International (STTI) is a nonprofit
organization founded in 1922 whose mission is advancing world health and
celebrating nursing excellence in scholarship, leadership, and service. Members
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To order additional books, buy in bulk, or order for corporate use, contact Nurs-
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ISBN: 9781940446844
EPUB ISBN: 9781940446851
PDF ISBN: 9781940446868
MOBI ISBN: 9781940446875
_______________________________________________________________________
Library of Congress Cataloging-in-Publication data
Names: Crisp, Donna Helen, 1947- author. | Sigma Theta Tau International,
issuing body.
Title: Anatomy of medical errors : the patient in room 2 : a nurse’s story of
surviving preventable medical errors and discovering the truth / Donna
Helen Crisp.
Description: Indianapolis, IN : Sigma Theta Tau International, [2017] |
Includes bibliographical references. | Description based on print version
record and CIP data provided by publisher; resource not viewed.
Identifiers: LCCN 2016021297 (print) | LCCN 2016020941 (ebook) | ISBN
9781940446851 (Epub) | ISBN 9781940446868 (Pdf) | ISBN 9781940446875 (
Mobi) | ISBN 9781940446844 (print : alk. paper) | ISBN 9781940446851
(EPUB) | ISBN 9781940446868 (PDF) | ISBN 9781940446875 (MOBI)
Subjects: | MESH: Medical Errors | Hysterectomy | Intraoperative
Complications | Malpractice | Patient Harm | Nurses | Personal Narratives
Classification: LCC R729.8 (print) | LCC R729.8 (ebook) | NLM WP 468 | DDC
610.28/9--dc23
LC record available at https://lccn.loc.gov/2016021297
________________________________________________________________________
First Printing, 2016
PUBLISHER: Dustin Sullivan DEVELOPMENT AND PROJECT EDITOR:
ACQUISITIONS EDITOR: Emily Hatch Carla Hall
EDITORIAL COORDINATOR: Paula Jeffers COPY EDITOR: Meaghan O’Keeffe
COVER DESIGNER: Rebecca Batchelor PROOFREADERS: Jane Palmer,
Erin Geile, Nancy Sixsmith
BOOK DESIGN & LAYOUT:
Rebecca Batchelor
DEDICATION
To my mother and father,
who taught me to fight for justice.
To my family and Shakespeare,
who taught me to love words.
ACKNOWLEDGMENT
Without my conjuring up his brilliance with language and plot,
William Shakespeare became part of my writing journey from the
beginning of this project. With no thought or intention to use any-
one’s quotations, I somehow felt compelled to consult Shakespeare,
beginning in the early days, when I first began to write down the
details of what happened to me.
Throughout the years of writing this book, I did not tell Shakespeare
to stay or to go away. I just observed his presence along every twist
and turn of my writing. Only in the final stages of completing my
manuscript did I begin to think of my story as a true tragedy. Then,
it made sense that Shakespeare, a master of tragedy, had helped me
tell my story. I am grateful for his inspiration and honored for his
assistance.
