prises is their capacity to learn and change (Quinn, 1992). This is an important reminder. When considering the recommendations for change presented in this report, the reader may have any one of a number of different responses, ranging from wishing to jump right in, to wanting to wait to undertake new changes until things settle down a bit, to seeking to determine what recommendations are most important and which can be deferred. However, the committee calls attention to evidence that should influence how HCOs and the other entities addressed in this report respond to its recommendations:

  • The turbulence experienced by the health care industry is not predicted to lessen. HCOs and other entities that have roles to play in protecting patient safety should not wait to make necessary changes.

  • None of the committee’s recommendations are of lesser importance; entities will need to act on all of the recommendations to keep patients safe.

  • While some recommendations may have immediate cost implications for some organizations, their implementation also is likely to produce benefits (some financial) for all organizations in addition to enhancing patient safety.

  • Organizations and individuals need to maintain the capacity for ongoing change and adoption of new work strategies and processes as further research provides additional information on how to increasingly improve support for and deployment of nursing staff to maximize patient safety.


The health care system continues to evolve, responding to pressures and opportunities:

  • Health care spending in the United States grew 9.6 percent in 2002, nearly four times faster than the overall economy. However, while this increase is very high, it represented the first slowing of the growth rate in 5 years, a slowdown that occurred in all four categories of health care spending—inpatient and outpatient care, prescription drugs, and physician services (Center for Studying Health System Change, 2003).

  • Although the transition to less-restrictive managed care has eased financial pressures on providers, declining Medicare and Medicaid payments continue to squeeze hospitals and physicians. Providers are pressing health plans for better payment rates and contract terms, and hospitals and physicians are increasingly competing for profitable specialty medical and ancillary services, resulting in a continued buildup of capacity and technology. In Indianapolis, for example, six new specialty hospitals have opened or are

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