6
Work and Workspace Design to Prevent and Mitigate Errors

The largest, best-trained, and most dedicated workforce will still make errors; its fallibility is an immutable part of human nature. However, this innate fallibility can be compounded when the practices, procedures, tools, techniques, and devices used by workers are unreliable, complex, and themselves unsafe—having been designed, selected, and maintained by other fallible humans.

The two Institute of Medicine (IOM) reports discussed earlier in this report—To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001)—call for better design of work processes to improve patient care and safety. To Err Is Human recommends that health care organizations (HCOs) incorporate safety principles in work design. Crossing the Quality Chasm underscores this recommendation by observing that “health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set up the workforce to fail, regardless of how hard they try (IOM, 2001:4).” The report reiterates that safer health care requires redesigned health care processes.

Some nursing processes, such as medication administration, are well documented to have multiple features conducive to the commission of health care errors. The long work hours of some nurses also cause fatigue and contribute to their making errors. Inefficient care processes and workspace design, while not intrinsically dangerous to patients, decrease patient safety to the extent that they reduce the time nurses have for monitoring patients and providing therapeutic care. Documentation and paperwork requirements are well known to involve such inefficiencies.



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Keeping Patients Safe: Transforming the Work Environment of Nurses 6 Work and Workspace Design to Prevent and Mitigate Errors The largest, best-trained, and most dedicated workforce will still make errors; its fallibility is an immutable part of human nature. However, this innate fallibility can be compounded when the practices, procedures, tools, techniques, and devices used by workers are unreliable, complex, and themselves unsafe—having been designed, selected, and maintained by other fallible humans. The two Institute of Medicine (IOM) reports discussed earlier in this report—To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001)—call for better design of work processes to improve patient care and safety. To Err Is Human recommends that health care organizations (HCOs) incorporate safety principles in work design. Crossing the Quality Chasm underscores this recommendation by observing that “health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set up the workforce to fail, regardless of how hard they try (IOM, 2001:4).” The report reiterates that safer health care requires redesigned health care processes. Some nursing processes, such as medication administration, are well documented to have multiple features conducive to the commission of health care errors. The long work hours of some nurses also cause fatigue and contribute to their making errors. Inefficient care processes and workspace design, while not intrinsically dangerous to patients, decrease patient safety to the extent that they reduce the time nurses have for monitoring patients and providing therapeutic care. Documentation and paperwork requirements are well known to involve such inefficiencies.

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Keeping Patients Safe: Transforming the Work Environment of Nurses The committee agrees that nurses’ work processes and workspace need to be designed to make them more efficient, less conducive to the commission of errors, and more amenable to detecting and remedying errors when they occur. In addition, limiting the number of hours worked per day and consecutive days of work by nursing staff, as is done in other safety-sensitive industries, is a fundamental patient safety precaution. It is also essential to foster collaboration of nursing staff with other health care personnel in identifying high-risk and inefficient work processes and workspaces and (re)designing them for patient safety and efficiency. Redesign of patient care documentation practices, however, cannot be accomplished solely by nursing staff and internal HCO efforts. Because many documentation practices are driven by external parties, such as regulators and oversight organizations, these organizations will need to assist in the redesign of those practices. This chapter reviews the evidence on the design of nurses’ work hours, work processes, and workspaces, primarily as they relate to patient safety, but also with respect to efficiency (which, as noted above, is a contributory factor in safety). We present findings and recommendations derived from this evidence on designing these elements of the nursing environment so as to enhance safety. DESIGN OF WORK HOURS This section reviews the evidence related to the design of nurses’ work hours: the effect of fatigue from shift work and extended work hours on work performance, the relationship between nurse work hours and the commission of errors, and data on hours worked by both hospital and nursing home nursing personnel. The committee’s responses to this evidence in the form of conclusions and a recommendation are then presented. Effect of Fatigue from Shift Work and Extended Work Hours on Work Performance1 Fatigue results from continuous physical or mental activity, inadequate rest, sleep loss, or nonstandard work schedules (e.g., working at night). Whatever the origin of physical or mental fatigue, it is accompanied by a subjective feeling of tiredness and a diminished capacity to do work. The effects of fatigue include slowed reaction time, diminished attention to detail, errors of omission, compromised problem solving (Van-Griever and 1   This section incorporates content from a paper on “Work Hour Regulation in Safety-Sensitive Industries” commissioned by the committee and included in this report as Appendix C.

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Keeping Patients Safe: Transforming the Work Environment of Nurses Meijman, 1987), reduced motivation, and decreased vigor for successful completion of required tasks (Gravenstein et al., 1990). Thus, fatigue also causes decreased productivity. Tired workers accomplish less, especially if their tasks demand accuracy (Krueger, 1994; Rosa and Colligan, 1988). In nurses’ work environments, fatigue is produced by shift work and extended work hours. Shift Work Since almost all physiological and behavioral functions are affected by circadian rhythms, the time of day when work must be completed is important. The human circadian rhythm strongly favors sleeping during nighttime hours. Overall capacity for physical work is reduced at night (Cabri et al., 1988; Cohen and Muehl, 1977; Rosa, 2001; Wojtczak-Jaroszowa and Banaszkiewicz, 1974). Reaction times, visual search, perceptual–motor tracking, and short-term memory are worse at night than during the day (Folkard, 1996; Monk, 1990). On-the-job performance also deteriorates. At night, railroad signal and meter reading errors increase, minor errors occur more frequently in hospitals, and switchboard operators take longer to respond to phone calls (Monk et al., 1996). Night shift workers also have difficulty staying awake. In a survey of nurses working in seven West Coast hospitals, 19.3 percent of those working night and rotating shifts reported struggling to stay awake at least once during the previous month while taking care of patients, compared with 3.8 percent of day and evening shift nurses (Lee, 1992). In a 1986 study of nurses in one hospital, 35.3 percent of those who routinely rotated to the night shift, 32.4 percent of those who always worked nights, and 20.7 percent of day/evening shift nurses who worked occasional nights reported falling asleep during the night shift at least once a week. Nurses working night shifts or rotating shifts also made more on-the-job procedural and medication errors due to sleepiness than did nurses working other shifts. Sleepiness appeared to be confined to the night shift, as none of the shift rotators or day/evening nurses who worked occasional nights reported significant difficulties remaining alert on other shifts (Gold et al., 1992). Likewise, objective findings of sleeping on duty were reported in a study of 15 French nurses working at night. Only 4 of the 15 were able to remain awake all night while at work as measured by activity (wrist actigraphy) and sleep (polysomnographic) recordings; the remaining nurses averaged 86.5 (standard deviation ± 77.6) minutes of sleep while on duty (Delafosse et al., 2000). Difficulties in maintaining alertness at night are not confined to nurses. Self-reported and objective measures of sleep were recorded in U.S. Air Force traffic controllers on duty at night (Luna et al., 1997). And the most consistent factor influencing truck driver fatigue and alertness over a

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Keeping Patients Safe: Transforming the Work Environment of Nurses 16-week study of 80 commercial truck drivers was time of day. Episodes of drowsiness at the wheel were observed in the majority of drivers. Drowsiness was markedly greater during nighttime than daytime driving (Wylie et al., 1996). Coping with nonstandard work hours (nights or rotating shifts) is easier for someone fully rested. A person who is not sleep deprived performs tasks more efficiently after prolonged wakefulness (Dinges et al., 1996). However, individuals working nights and rotating shifts rarely obtain optimal amounts of quality sleep. Their sleep is shorter, lighter, more fragmented, and less restorative than sleep at night (Knauth et al., 1980; Lavie et al., 1989; Walsh et al., 1981). A number of interventions have been proposed to mitigate the effect of shift work. Clockwise shift rotations—day shift, progressing to evening, then night shifts—appear to be tolerated more easily than the reverse. Scheduled, on-the-job naps and use of bright lighting also have been found to combat fatigue to some extent. However, the way in which they are best implemented has not been established. The speed of shift rotation, how to counteract the sleep inertia that commonly accompanies the taking of naps, and how to provide bright lighting for nurses while maintaining optimal darkness for patients are some of the issues not yet resolved. Consequently, experts on fatigue have recommended modifying work tasks and processes to reduce the risk for error and creating mechanisms to detect errors at the time they are committed to reduce their adverse effects (Office of Technology Assessment, 1991; Jha et al., 2001). Extended Work Hours Shifts of 12 or more hours with limited opportunity for rest and no opportunity for sleep are referred to as “sustained operations” (Kruger, 1989). Workers engaged in sustained operations in a variety of occupations report greater fatigue at the end of their shifts than do those who work 8-hour shifts (Mills et al., 1983; Rosa, 1995; Ugrovics and Wright, 1990).2 Studies in a variety of industries also show that accident rates increase during overtime hours (Kogi, 1991; Schuster, 1985); rates rise after 9 consecutive hours, double after 12 hours (Hanecke et al., 1998), and triple after 16 hours (Akerstedt, 1994). Data from aircraft accident investigations 2   In two studies, however, mine workers reported no differences in fatigue after 8- and 12-hour shifts despite high physical workloads (Duchon et al., 1994), and computer operators reported reduced tiredness throughout the shift after switching from 8-hour to 12-hour shifts (Williamson et al., 1994). Neither study reports the timing and duration of meal and “coffee” breaks. In the case of unionized mine workers, it is likely they were provided brief rest periods during their work shifts.

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Keeping Patients Safe: Transforming the Work Environment of Nurses conducted by the National Transportation Safety Board also show higher rates of error after 12 hours (National Transportation Safety Board, 1994). Finally, night shifts longer than 12 hours and day shifts longer than 16 hours have consistently been found to be associated with reduced productivity and more accidents (Rosa, 1995). Laboratory studies have shown that moderate levels of prolonged wakefulness can produce performance impairments equal to or greater than those due to levels of intoxication deemed unacceptable for driving, working, and/or operating dangerous equipment. Prolonged periods of wakefulness (e.g., 17 hours without sleep) can produce performance decrements equivalent to a blood alcohol concentration (BAC) of 0.05 percent, the level defined as alcohol intoxication in many western industrialized countries.3 After 24 hours of sustained wakefulness, cognitive psychomotor performance decreases to a level equivalent to a BAC of 0.10 percent (Dawson and Reid, 1997; Lamond and Dawson, 1998). Performance on neurobehavioral tests decreases linearly after 17 hours of wakefulness, with the poorest performance occurring after 25–27 hours. Performance on the most complex task—grammatical reasoning—was found to be impaired several hours earlier than performance on vigilance accuracy and response latency (20.3 hours versus 22.3 and 24.9 hours, respectively) (Lamond and Dawson, 1998). Prolonged wakefulness also significantly impairs speed and accuracy, hand–eye coordination, decision making, and memory (Babkoff et al., 1988; Florica et al., 1968; Gillberg et al., 1994; Linde and Bergstrom, 1992; Mullaney et al., 1983). A nurse who worked on average one mandatory double shift (16 hours) every 2 weeks for a 2-month period reported, “By 4 a.m., I was so exhausted that I would stop between going from one baby to the next and completely forget why I was going to the other bedside. Another time, again about 4 a.m., I would sometimes stop in the middle of the floor and forget what I was doing” (California Nurses Association, 2003). Fatigue is also exacerbated by working increased numbers of shifts without a day off (Dirks, 1993; Knauth, 1993) and by having only short durations between work shifts. Working more than four consecutive 12-hour shifts is associated with excessive fatigue and longer recovery times (Wallace and Greenwood, 1995). Very short off-duty periods—8 hours or less—do not provide enough time for commuting, recovery sleep, or time to take care of domestic responsibilities (Dinges et al., 1996; Rosa, 1995, 2001). Most adults require at least 6–8 hours of sleep to function adequately at work (Krueger, 1994). The loss of even 2 hours of sleep affects waking 3   In the United States, BAC-level definitions of intoxication are set by the states. Limits of 0.08 and 0.10 are typical for adult drivers; the majority of states set lower levels for drivers under 21 years of age, such as 0.00–0.07 (Wagenaar et al., 2001).

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Keeping Patients Safe: Transforming the Work Environment of Nurses performance and alertness the next day (Dinges et al., 1996). After 5 to 10 days of shortened sleep periods, the sleep debt (sleep loss) is significant enough to impair decision making, initiative, information integration, planning, and plan execution (Krueger, 1994). The effects of sleep loss are insidious and usually not recognized by the sleep-deprived individual until they have become severe (Dinges et al., 1996; Rosenkind et al., 1999). Schedules that require workers to return to work after an 8-hour rest period or to transition from night to day or evening shifts without at least 24 hours off are considered particularly dangerous (Olson and Ambrogetti, 1998; Rosa and Colligan, 1988). Recovery from extended work periods requires more than 1 day. Off-duty intervals ranging from 10 to 16 hours are either suggested or already mandated for many transportation workers (Dinges et al., 1996; Gander et al., 1991; Mitler et al., 1997). Two consecutive nights of recovery sleep can return performance and alertness to normal levels, even following two or three 12-hour shifts (Dinges et al., 1996; Tucker et al., 1996); longer intervals between works days are even more beneficial. Workers obtain more sleep and start their next shift with less fatigue. The first or second night on a new series of night shifts, however, may be the most fatiguing because of circadian desynchrony (Rosa, 2001). The combination of sustained wakefulness and working at night is particularly hazardous (Gold et al., 1992; Smith et al., 1994). When the Exxon Valdez ran aground around midnight on March 23, 1989, the third mate had been awake 18 hours and anticipated working several more hours (Alaska Oil Spill Commission, 1990). Although the explosion of the Challenger space shuttle occurred during the daytime, the decisions made the night before the launch by mission control staff have been cited as a major factor contributing to the explosion (Mitler et al., 1988). In a small study of the use of extended (16-hour) night shifts in seven wards of a Japanese university hospital, several compensatory measures were employed to protect against the dual effects of sustained operations and night shift work. These measures included increases in the numbers of night staff to allow all nursing staff to take a 2-hour nap in a dedicated resting room. Staff was also allowed to take at least one recovery day off after a 16-hour shift. The increase in staff, 2-hour nap, and day off were believed to contribute to the extended shift nurses’ less frequent complaints of fatigue and general decreased physical activity as compared with nurses working 8-hour shifts (Fukuda et al., 1999). The study also found that sleep inertia (characterized by sleepiness, fatigue, and dullness) increased immediately after the nap, but then decreased to the same levels as existed before the nap. The researchers concluded that nap length would need to be carefully regulated to avoid persistent sleep inertia and its attendant risks (Takahashi et al., 1999).

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Keeping Patients Safe: Transforming the Work Environment of Nurses A review of evidence on the effects of worker fatigue on patient safety is included in the Agency for Healthcare Research and Quality’s (AHRQ) report Making Health Care Safer: A Critical Analysis of Patient Safety Practice (Jha et al. 2001). Consistent with the above evidence, the report notes that sleep deprivation leads to decreased alertness and poor performance on standardized testing, and that shift workers in particular experience disturbances in their circadian rhythms and tend to perform less well on reasoning and nonstimulating tasks. Evidence on Nurse Work Hours and the Commission of Errors Researchers conducting the evidence review presented in the AHRQ report cited above (Jha et al., 2001) were unable to locate research that could help identify the specific numbers of hours worked by health care personnel, including nurses, beyond which patient safety is threatened. These researchers noted inconsistent research findings with respect to ideal shift length for enhanced worker performance. The report suggests that while multiple studies have sought to document the impact of fatigue on the performance of medical personnel, these studies have been limited by poor design or outcomes that did not correlate well with medical error. This situation has been improved by a 2002 study funded as part of AHRQ’s initiative to examine the effects of working conditions on patient safety. This study documented the work patterns of a sample of hospital staff nurses randomly selected from the membership of the American Nurses Association (ANA). The sample frame consisted of full-time hospital staff nurses (unit based, not working through a temporary agency) with no administrative or educational responsibilities. The study measured the effects of nurse work hours on patient safety by (1) documenting the total scheduled and unscheduled hours worked by nurses; (2) describing the nature of nurses’ overtime work hours in terms of what proportion of hours worked were overtime hours, how often nurses worked overtime, and whether overtime was voluntary or mandatory; and (3) determining whether there was an association between errors and near-errors and the numbers and types of hours worked by the nurses. Study participants recorded information about their scheduled work hours, actual work hours, errors, and near-errors daily in a diary for 28 days. Nurses were also asked to describe all errors and near-errors. The researchers then categorized each error or near-error by type (e.g., medication administration, procedural, transcription) based on the nurse’s description. Error rates per hour were calculated according to the number of errors and hours worked, adjusting for multiple work shifts for the same nurse. The associations between error rates and both overtime and scheduled work

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Keeping Patients Safe: Transforming the Work Environment of Nurses shift duration (in hours) were estimated using regression models. The p-values for the adjusted incidence rate ratios were constructed based on robust variance estimates, with α = 0.05. Near-errors were examined using the same procedures. For all study nurses, the overall error rate was 0.00336 errors per hour worked. Working overtime—working longer than scheduled on a given day or working extra shifts (“scheduled overtime”)—had no effect on error rates unless shift durations exceeded 12 consecutive hours. Once shift durations exceed 12 consecutive hours, both voluntary and mandated overtime significantly increased error rates (0.00375/hour and 0.00490/hour, respectively) (p = 0.02 for voluntary overtime and 0.03 for mandated overtime). Results remained consistent when outliers (i.e., 54 extremely long shifts of more than 23 hours, nurses with more than 7 errors each) were removed from the analyses. Results were somewhat different for near-errors. Being mandated to work overtime was associated with significant increases in the rate of near-errors for shifts scheduled for 12 hours or more; however, the rate of near-errors associated with working voluntary overtime for periods exceeding 12 consecutive hours was not increased.4 Data on Nurse Work Hours Nursing staff working in in-patient facilities have traditionally worked in 8-hour shifts, but increasingly work longer hours. Reasons for these increases include the desire for increased compensation (elective overtime), requirements by health care organizations to work overtime (mandatory overtime) to compensate for insufficient staffing, and the desire for more flexible work hours (e.g., 10- or 12-hour shifts) to accommodate either facility or individual nurse needs or both. Scheduled shifts may be 8, 10, or 12 hours and may not follow the traditional pattern of day, evening, or night shifts. Nurses working on specialized units, such as the operating room, dialysis units, and some intensive care units, may be required to be on call in addition to their regularly scheduled shifts (Rogers, 2002). Representative, quantitative data describing the work hours of nurses are scarce. Evidence of the long hours worked by direct-care nurses working in hospitals and nursing homes was obtained from a random sample survey of nurses licensed to work in either Illinois or North Carolina5 as part of a longitudinal study of nurses’ worklife and health funded by the 4   Unpublished study data from Ann Rogers, Ph.D., University of Pennsylvania (personal communications on January 25, 2003, June 29, 2003 and July 18, 2003). 5   These states were selected because they have large ethnic diversity in their registered nurse (RN) populations and because they renew RN licenses annually, providing up-to-date mailing lists.

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Keeping Patients Safe: Transforming the Work Environment of Nurses National Institute for Occupational Safety and Health (NIOSH) of the U.S. Centers for Disease Control and Prevention (CDC). Of the 674 registered nurse (RN) respondents to this 2002–2003 survey who were employed as a full-time hospital or nursing home general-duty/staff nurse, 27.2 percent reported working more than 13 hours at a stretch one or more times a week, and an additional 18.9 percent reported doing so once a month or every other a week. Only 19.5 percent reporting never doing so, while 34.4 percent reported doing so only a few times per year.6 Extended work hours also are indicated by their frequently being cited by nurses as a key area of job dissatisfaction (U.S. General Accounting Office [GAO], 2001); by the extent to which nursing organizations have sought legislative, regulatory, and contractual relief from this practice; and by the few studies of hours worked by nursing staff in hospitals and nursing homes. Work Hours of Hospital Nurses Data collected from the 2000 National Sample Survey of Registered Nurses indicate that full-time hospital nurses (including direct-care, administrative, and other hospital nurses) worked on average 42.2 hours per week, in contrast to their average scheduled hours of 39.3 hours per week (Spratley et al., 2000). In 2001, 17 percent of a national representative sample of newly licensed RNs surveyed by the National Council of State Boards of Nursing in its twice yearly survey of entry-level nurses reported working (in all settings of care, full- and part-time) an average of 36.5 nonovertime hours per week and an average of 4.6 hours of overtime per week. Likewise, 17 percent of these newly licensed RNs reported working mandatory overtime (Smith and Crawford, 2002). As the discussion of staffing levels in Chapter 5 indicates, however, averages do not tell the full story. The AHRQ-funded study of the work hours of a sample of members of the ANA documented the variation in the work patterns of full-time, direct-care hospital staff nurses in terms of hours worked, duration of shifts, and amount of overtime hours worked. The study found that although the majority (84.3 percent) of scheduled shifts were 8 or 12 hours in duration, 3.5 percent were for periods greater than 12 hours. Scheduled shift durations ranged from 2 to 22.5 hours (see Figure 6-1). Furthermore, a comparison of scheduled and actual work times revealed that all nurses had started work earlier than scheduled, stayed later than scheduled, or both at least once during the 28-day period. Nurses reported working on average 13.4 days (range 1–24) during this 28-day data-gather- 6   Unpublished data from Alison Trinkoff, Ph.D., University of Maryland at Baltimore, NIOSH grant R01OH3702 (personal communication, April 9, 2003).

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Keeping Patients Safe: Transforming the Work Environment of Nurses ing period, and working beyond their scheduled shift times on average 10.9 days (range 1–24). Nurses started work early, left later than scheduled, or both on 81.4 percent of shifts. As a result, actual (as opposed to scheduled) work shift durations ranged from 1 hour, 15 minutes (an obstetrical nurse who was sent home because of a low census) to 23 hours, 57 minutes (see Figure 6-1). Almost half of the shifts worked (43 percent) exceeded 12 hours (1074 shifts), and one-quarter exceeded 12 hours, 50 minutes. There were 51 double (16-hour) shifts reported, 51 shifts in which participants worked more than 16 but less than 20 hours, and 103 shifts that exceeded 20 consecutive hours. A comparison of actual and scheduled work times revealed that participants worked on average 1 hour, 9 minutes extra per scheduled shift (range 18 minutes–19 hours, 30 minutes). Work Hours of Nursing Staff in Nursing Homes Research on the work hours of nursing staff in nursing homes also has revealed extended work hours. In site visits to 17 nursing homes in Ohio, Colorado, and Texas in 2001, researchers found that double shifts (i.e., two FIGURE 6-1 Scheduled and actual shift durations. SOURCE: Ann Rogers, Ph.D., University of Pennsylvania (personal communication on July 4, 2003).

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Keeping Patients Safe: Transforming the Work Environment of Nurses consecutive 8-hour shifts totaling 16 hours) and extra shifts were performed in many of these facilities on a regular basis. Double shifts in particular were pervasive. In 13 of the 17 nursing homes, at least one nursing staff member, but frequently more, had worked between one and three double shifts in the previous 7 days. In five nursing homes, at least one staff member had worked between four and seven double shifts in the last 7 days. In one of the facilities, more than a third of the interviewed nursing staff had worked between eight and eleven double shifts in the last 14 days. All direct-care nursing staff (RNs, licensed practical nurses [LPNs]/licensed vocational nurses [LVNs], and nursing assistants [NAs]) were engaged in these work practices; however, double shifts were performed most often by NAs (Centers for Medicare and Medicaid Services [CMS], 2002). Responses to the Evidence The committee finds the evidence that prolonged work hours and fatigue affect worker performance to be very strong. We also note that there is no evidence to suggest that any amount of training, motivation, or professionalism is able to overcome the performance deficits associated with fatigue, sleep loss, and the sleepiness associated with circadian variations in alertness (Battelle Memorial Institute, 1998; Dinges et al., 1996; Jha et al. 2001; McCartt et al., 2000). The recent AHRQ-funded study of nurse work hours and health care errors discussed above provides additional compelling evidence of the effect of nurses working long hours on patient safety. The committee reviewed evidence on how other safety-sensitive industries—nuclear energy production, public and commercial transportation, the military, police, and firefighters—have responded to such evidence. All have placed some restrictions on the work hours of personnel (see Appendix C). The health care industry is notable in that, with few exceptions, it places no such limits on work hours. However, a number of organizations are beginning to respond to the evidence. As of 2002, eight states had enacted legislation or regulations prohibiting facilities from requiring nurses to work certain extended hours (ANA, 2002). Legislation also has been introduced federally and within additional states to ban mandatory overtime for nurses. The Safe Nursing and Patient Care Act of 2003 (HR 745 and SB 373), introduced in the 108th U.S. Congress, would, in part, prohibit mandatory overtime for nurses and other licensed health care providers. As part of the ANA’s nationwide state legislative agenda, other state nurses’ associations are pressing for prohibitions on mandatory overtime in state statutes and regulations. No proposals address how long nurses may work on a voluntary basis. Jha et al (2001:530) note that “in most high-hazard industries the assumption is that fatigue and long, aberrant work hours leads to poor

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Keeping Patients Safe: Transforming the Work Environment of Nurses Nursing Unit Design Elements of Workspace Design LEAN Principles Learning center Such a center provides electronic access to hospital policies/procedures/nursing information if possible, as well as access to e-learning and reference material on nursing units. Improve knowledge among nursing staff, and provide immediate access to reference materials in a timely fashion to reduce errors. Staff lounge The staff lounge provides private space with adequate accommodations. When possible, it has a window to the outside. The lounge supports caregivers by providing an “off-stage” area for downtime. Reduce caregiver stress; offer caregivers privacy. Physician–nurse collaboration areas Private areas for consultation and collaboration are needed to promote professional interdisciplinary practice. Decentralized nursing stations can detract from staff privacy; an alternative area is needed for compliance with HIPAAb patient privacy provisions as well. Provide space for team-centered care. Reduce errors and improve care processes through collaboration. Supplies and equipment Adequate space for storage of patient equipment should be conveniently located in the core space out of the hallway. Automated supply systems should be standardized and matched against patient populations.   Medication delivery Robotic, automated, or mobile carts should be conveniently distributed on the unit with adequate ratios to nursing unit size. Eliminate the need to stand in line to get drugs. Prevent nurse “pocket storage” from automated systems by eliminating lines for access. aThis does not apply to neonatal intensive care units, where exposure to direct sunlight has risks for the pre-term infant (Graven, 1997). bHealth Insurance Portability and Accountability Act of 1996.

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Keeping Patients Safe: Transforming the Work Environment of Nurses The role of the ergonomist is the subject of debate in the field of human factors and ergonomics. Drury (1995:66–67) argues that “there is no substitute for the ergonomist’s knowledge and understanding of both the system under study and the ergonomics literature.” Gosbee (2002:354) argues that “[human factors engineering] must become a core competency of anyone who has significant involvement in patient safety activities.” Corlett (1991:418) states that “[we must] give ergonomics away, … transfer our knowledge and methods to others who are closer to the places where changes have to be made, so that they do much of the ergonomics for themselves…. Until ergonomics is widely practiced by other than professional ergonomists, it is likely to remain something to be added on at the end.” The committee concludes that the dissemination and application of work design knowledge and skills throughout individual HCOs needs to be achieved through multiple mechanisms, including trial and error, creation of in-house expertise, use of consultants, and various education and training mechanisms. HCOs should undertake efforts to increase the knowledge of end users—the nurses whose work is being redesigned—about work design through, for example, on-the-job coaching or continuing education programs. As the complexity of work design initiatives increases, however, there is likely to be a commensurate increased need for professional consultation. The committee makes the following recommendations: Recommendation 6-2. HCOs should provide nursing leadership with resources that enable them to design the nursing work environment and care processes to reduce errors. These efforts must directly involve direct-care nurses throughout all phases of the work design and should concentrate on errors associated with: Surveillance of patient health status. Patient transfers and other patient hand-offs. Complex patient care processes. Non–value-added activities performed by nurses, such as locating and obtaining supplies, looking for personnel, completing redundant and unnecessary documentation, and compensating for poor communication systems. The committee notes that “resources” should include time and financial and consultant resources, as necessary. Recommendation 6-3. HCOs should address handwashing and medication administration among their first work design initiatives.

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