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New nurse, familiar story lead to patient infection
What would be gained if I told anyone?’
A recent patient safety report by an Institute of Medicine committee in Washington, DC, includes the following true firsthand account of a staffing problem leading to a nosocomial infection. "While this error involved an inexperienced nurse, errors are committed by individuals with all levels of experience," the report states.1
"I was a new’ nurse. I’d been practicing only a few months when I was assigned an elderly patient who was scheduled for abdominal surgery that morning and needed a urinary catheter inserted. I knew about, but hadn’t performed, this procedure before, and neither had the other nurses on the floor — we all were new graduates and fairly inexperienced. I asked my head nurse if she would supervise me while I placed the catheter, but she was late for a meeting and assured me that it wasn’t difficult and I would be fine.
"I went to get the supplies I needed, but there were no prepackaged catheterization trays on the floor. I ran the stairs to the floors above and below me, but they were out, too. As I passed the nursing station, the clerk called out to me that the OR wanted to know where the patient was. I began to round up the materials needed on an item-by-item basis. 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, [The patient] 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?"
1. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC; 2003.