First, Do No Harm

Amiddle-aged woman with a history of metastatic cancer arrived at the emergency room of a small community hospital in acute distress and with sudden-onset gastric bleeding. Laboratory results showed that she was severely anemic, and the attending physician in the emergency department ordered 2 units of blood. The woman’s blood was quickly typed and cross-matched, and the blood units arrived just as she was being transferred to one of the medical units. It was an unusually busy day in the emergency room; there were several trauma patients who were accompanied by anxious, sometimes hostile, families. Gurneys were stacked up in the hallways, as emergency department staff waited for radiograph and laboratory results. Staff members were eager to get the blood unit started and transfer this particular patient, as well as several other patients, before the change of shift. One of the nursing staff started the first unit of blood, and the nurse assigned to the patient prepared the paperwork for transfer—all while juggling multiple interruptions. Moments after the woman’s husband was sent to the admitting office, she became anxious and said that she was having difficulty breathing. She clung to her nurse’s hand, refusing to let the nurse leave her side and begging the nurse to help her. Her breathing became increasingly rapid, and she began to panic. She complained of chest pain and nausea. The nurse, a new graduate, wondered if the patient was having a heart attack. The nurse had never seen a patient in such acute distress. Vital signs indicated that the patient was going into shock. The only physician in the emergency room was busy suturing a difficult wound, and the other nurses were busy elsewhere. What should the nurse do? Within seconds, the patient went into cardiac arrest; during the code, one of the staff discovered that the patient was being given the wrong unit of blood, a unit meant for another patient. The transfusion was stopped immediately and resuscitation was initiated, but the patient died. Although this incident happened many years ago, the nurse (KD) responsible for that patient will never forget the patient’s look of desperation. It was a sad glimpse into the huge responsibility that every nurse and physician has to “First, do no harm.” Assessing the Landscape of Patient Safety We were reflecting on this tragic incident and the sea of change related to medical errors that has occurred during the past few years. Between the 2 of us, we have accumulated a half century of clinical experience. We each have witnessed unfortunate (and avoidable) tragedies, as well as many “near misses.” The tragedies often involved incidents in which, despite the best intentions of knowledgeable clinicians, patients were harmed and sometimes died. It is these types of occurrences that the Institute of Medicine (IOM) wrote about 5 years ago. 1