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 Committee on the Work Environment for Nurses and Patient Safety was formed to carry out this study. This report presents the study results.

In responding to its charge, the committee reviewed and built upon recommendations for increasing patient safety contained in two earlier IOM reports—To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). In this introductory chapter, we first summarize and update the evidence presented in To Err Is Human about the magnitude and etiology of health care errors affecting patient safety. We then present evidence of the key role played by nurses in patient care and safety, and briefly describe some of the characteristics of the current health care delivery system that shape the work and work environment of nurses, particularly in in-patient facilities. Evidence is then presented showing that nurses are not immune to the problems that plague health care delivery in the United States—problems that foster the occurrence of errors in which all health care providers, not just nurses, are involved. The chapter ends with a call for a substantial transformation in the work environment of nurses to better safeguard patients.


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 [operating room] wanted to know where the patient was. I began to round up the materials needed on an item-by-item basis.

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