I got a sterile prep tray (the last one), sterile catheter and gloves, antiseptics for cleansing, and drainage bag. I opened the sterile prep tray, prepared the patient, put on the sterile gloves, and realized I hadn’t opened the bottles of antiseptic before putting on the sterile gloves and that the routine sterile prep tray didn’t contain what I had expected. There were no more gloves in the patient’s room. I went to get more, cautioning the patient to not move, and leaving my sterile field unattended.
As I passed the nurses’ station, the clerk again called out: “The OR called again and they are really angry and want to know what’s keeping your patient. You are backing up the entire OR schedule!” I got the gloves and with trembling hands, uncertainty about the sterility of my “sterile field,” and not the best of technique, inserted the catheter.
A day or two later, I was charting on my patients and seated next to the patient’s resident, who exclaimed, “Mrs. X has the worst UTI [urinary tract infection] I’ve ever seen!”
I didn’t say anything. I was ashamed and afraid, and besides, the resident was already writing an order for antibiotics. There was nothing more to be done. What would be gained if I told anyone?
What happened to Mrs. X in the above (true) incident was a mistake—an error. Her urinary tract infection was an adverse event likely resulting from (at least in the opinion of the nurse performing the procedure) that error. While this error involved an inexperienced nurse, errors are committed by individuals with all levels of experience.
To Err Is Human helped the United States (and other countries) come to a better understanding of the likely hundreds of thousands of health care errors and adverse events that occur in the United States every year in which nurses, physicians, pharmacists, dentists, nurse aides, and assistants—in fact, all health care providers—are involved. First, To Err Is Human presented the vocabulary necessary to begin to better understand the problem:
Errors are failures of planned actions to be completed as intended, or the use of wrong plans to achieve what is intended.
Adverse events are injuries caused by medical intervention, as opposed to the health condition of a patient. A large proportion of adverse events are the result of errors. When the adverse event is the result of an error, it is considered a preventable adverse event.
Sometimes an error, such as giving a patient the wrong medication, may lead to no detectable adverse event. Other errors can temporarily or permanently harm the health of the patient or cause the person’s death. In