MOST EXPERIENCED NURSES, physicians, and other clinicians have been associated, in some 'way, with health care-associated harm. Adverse events in health care occur far too often. A recent study by the Office of Inspector General, US Department of Health and Human Services, determined that about 1 in 7 Medicare fee-for-service patients experienced a serious adverse event, and that an additional 1 in 7 experienced a less serious adverse event (Table). On the basis of our best estimates of the incidence of adverse events, it is reasonable to assume that the majority of experienced clinicians have been near one. And yet, at that moment that an event occurs, the clinician closest to it feels alone. How does one feel after patient harm occurs? Responsible? Guilty? Inadequate? Defensive? Angry?
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