the incident described above, the catheterization of the patient was not completed as intended. The process was replete with errors, including the nurse’s technique in catheterization, the nurse manager’s assumption that the new nurse could perform the procedure safely, and the supply department’s failure to stock prepackaged catheterization trays on the floor. The patient received an injury—a urinary tract infection—an adverse event that was likely preventable. The infection likely caused discomfort and possibly even pain. It required the administration of antibiotics, which carries the risk of side effects, adverse reactions, and medication errors. Moreover, the administration of antibiotics may have prolonged the patient’s stay in the hospital. Urinary tract infections can also lead to more serious kidney infections and, if undetected or occurring in a patient with a weakened immune system, can lead to sepsis (an infection in the blood), which can cause death.

To Err Is Human also calls attention to the magnitude of adverse events that occur every day to patients in the hospital. The report estimates that adverse events (involving all health care providers) occur in 2.9 to 3.7 percent of acute care hospitalizations, and that approximately half of these events are likely due to errors (i.e., preventable adverse events). The report further estimates that each year, between 44,000 and 98,000 hospitalized Americans die as a result of medical errors—more than die from motor vehicle accidents, breast cancer, or AIDS. Indeed, To Err Is Human presents evidence that these numbers are likely underestimates of the numbers of people injured by errors in health care. These numbers also do not include persons injured as a result of medical errors in nursing homes, home health care, and other health care settings. Earlier studies of medical errors have indicated similarly high rates of adverse events (Steel et al., 1981).

The IOM’s estimates of high rates of errors have been reaffirmed more recently by two different sources—practicing physicians and the public at large. In a 2002 national survey of practicing physicians and the American public, 35 percent of surveyed U.S. physicians and 42 percent of the public reported experiencing an error either in their own care or in that of a family member. Moreover, 18 percent of the physicians and 24 percent of the public reported an error that had caused serious health consequences, including death (reported by 7 percent of physicians and 10 percent of the public), long-term disability (6 percent and 11 percent, respectively), and severe pain (11 percent and 16 percent). These were not the biased perceptions of distraught family members. About one-third of the respondents who reported experience with an error stated that the health professionals involved had told them about the error or apologized to them (Blendon et al., 2002).

The United States is not alone in its high rate of health care errors; research in other countries also has found high error rates. It is estimated that 10 percent of hospital patients in Great Britain and 16.6 percent of



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