Mitchell and Shortell, 1997; Rubenstein et al., 1992). Nursing vigilance also defends patients against errors. A study of medication errors in two hospitals over a 6-month period found that nurses were responsible for 86 percent of all interceptions of medication errors made by physicians, pharmacists, and others involved in providing medications for patients before the error reached the patient (Leape et al., 1995).

In reviewing evidence on acute hospital nurse staffing published from 1990 to 2001, the AHRQ report Making Health Care Safer: A Critical Analysis of Patient Safety Practices (Seago, 2001:430) concluded that “leaner nurse staffing is associated with increased length of stay, nosocomial infection (urinary tract infection, postoperative infection, and pneumonia), and pressure ulcers.… These studies … taken together, provide substantial evidence that richer nurse staffing is associated with better patient outcomes.” Subsequent studies have added to this evidence base and substantiate the observation that greater numbers of patient deaths are associated with fewer nurses to provide care (Aiken et al., 2002), and less nursing time provided to patients is associated with higher rates of infection, gastrointestinal bleeding, pneumonia, cardiac arrest, and death from these and other causes (Needleman et al., 2002). In caring for us all, nurses are indispensable to our safety.

NURSES’ WORK ENVIRONMENTS: A THREAT TO PATIENT SAFETY

In conducting this study, the committee reviewed evidence on the work and work environments of nurses; related health services, nursing, behavioral, and organizational research; findings from human factors analysis and engineering; and studies of safety in other industries. This evidence revealed that the typical work environment of nurses is characterized by many serious threats to patient safety. These threats are found in all four of the basic components of all organizations—organizational management practices, workforce deployment practices, work design, and organizational culture.

Frequent Failure to Follow Management Practices Necessary for Safety

Certain management practices are essential to the creation of safety within organizations and to the success of the organizational changes often needed to build stronger patient safety defenses. These practices include (1) balancing the tension between production efficiency and reliability (safety), (2) creating and sustaining trust throughout the organization, (3) actively managing the process of change, (4) involving workers in decision making pertaining to work design and work flow, and (5) using knowledge man-



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