Each of these safeguards is a defense against the occurrence of errors. As the work of experts in organizational safety attests, error-producing events can arise at any organizational level, within any organizational component, and within any work process. Safeguards are needed for each of these sources of patient safety errors; isolated defenses will be insufficient.

Redesigned work practices will still be unsafe if the number of nurses available to perform the work as designed is insufficient. Moreover, an apparently sufficient number of nurses will not perform as needed if they are suffering from the effects of fatigue, inexperienced in a given work process, or unfamiliar with the HCO’s work processes because they are secured from a temporary or travel nurse agency. And errors will still occur even when the most capable workforce provides care using the best-designed work processes, because neither the nurse nor the work process is perfect. Defenses against human errors can be developed and put in place only if nursing staff are not afraid of reporting the errors and are involved in designing even stronger defenses. Finally, instituting all of these defense strategies can be accomplished only by individuals who have a vision of and command resources for the organization as a whole—that is, an organization’s leadership and management. The actions of these leaders are the essential precursor to the creation of safer health care environments. They must be motivated by a passion to maximize the safety of all patients served by their institution. When implementing the committee’s recommendations, however, they may also observe some additional benefits to their institution.


The costs of implementing the committee’s recommendations will vary by facility and by recommendation. Some of the recommendations (e.g., establishment of a strong nursing leadership position, education and attention of governing boards with regard to safety, and adoption of management practices that are supportive of patient safety) are not likely to have significant immediate cost implications; other recommendations, such as limiting nurse work hours and ensuring safe staffing levels, may have such implications.

It is not possible to predict the costs that individual HCOs will face in implementing all of the committee’s recommendations. Costs will vary to the extent that organizations have already embraced these practices. Many of the recommendations (e.g., better work design and the creation of cultures of safety) echo those made in two prior Institute of Medicine (IOM) reports—To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001). As noted throughout the present report, a number of facilities have already undertaken many of those recommendations. Actions of the

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