In this context, and in recognition of evidence on the key role of nurses in patient safety, the U.S. Department of Health and Human Services’ (DHHS) Agency for Healthcare Research and Quality (AHRQ) asked the IOM to conduct a study to identify:

  • Key aspects of the work environment for nurses that likely have an impact on patient safety.

  • Potential improvements in health care working conditions that would likely increase patient safety.

AHRQ further directed that the study be conducted “in the context of current policy debates on regulation of nursing work hours and nursing workload … [and] cover such topics as: extended work hours and fatigue, including mandatory overtime; workload issues, including state regulation of nurse-to-bed ratios; workplace environmental issues, including poorly designed care processes; … workplace systems, including reliance on memory and lack of support systems for decision-making; and workplace communication, including social, physical, and other barriers to effective communication among care team members.” The IOM convened the Committee on the Work Environment for Nurses and Patient Safety to conduct this study.


The 2.8 million licensed nurses and 2.3 million nursing assistants providing patient care in this country represent approximately 54 percent of all health care workers and provide patient care in virtually all locations in which health care is delivered—hospitals; nursing homes; ambulatory care settings, such as clinics or physicians’ offices; private homes; schools; and employee workplaces. When people are hospitalized, in a nursing home, having a baby, or learning to manage a chronic condition in their own home—at some of their most vulnerable moments—nurses are the health care providers they are most likely to encounter; spend the greatest amount of time with; and, along with other health care providers, depend on for their recovery.

Research is now beginning to document what physicians, patients, other health care providers, and nurses themselves have long known: how well we are cared for by nurses affects our health, and sometimes can be a matter of life or death. As physicians in the American College of Critical Care Medicine have noted: “Critical care nurses do the majority of patient assessment, evaluation, and care in the ICU [intensive care unit]” (Brilli et al., 2001:2011). Nursing actions, such as ongoing monitoring of patients’ health status, are directly related to better patient outcomes (Kahn et al., 1990;

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