ADEs is realistic; a number of studies have indicated that between 28 and 95 percent of ADEs are preventable (AHRQ, 2001).

Tracking patient safety errors also can result in cost savings. At LDS Hospital in Salt Lake, such tracking identified 25 ADEs related to a new brand of the drug vancomycin. This brand was being used because it cost $5,000 per year less than the brand used previously. However, LDS discovered that treating the patients who suffered these ADEs cost $50,000 in extra care expenses. Without its error-tracking system, the hospital would have assumed it was saving $5,000 per year when it was actually spending an additional $45,000 per year (Classen et al., 1997).

However, HCOs should not wait for proof of the financial advantage that will accrue to them before pursuing the patient safety recommendations contained in this report. The committee believes that pursuit of patient safety is an ethical and professional obligation of those who work in a health care system that aims to “first, do no harm.” A number of HCO chief executive officers (CEOs) who are investing in high-cost patient safety systems and information technology infrastructure agree (Kinninger and Reeder, 2003; Solovy, 2003).


Changing health care delivery practices to increase patient safety must be an ongoing process. Research findings and dissemination of practices that individual HCOs have found successful in improving patient safety will help HCOs as learning organizations add to their repertoire of patient safety practices. The committee calls attention to several areas in which, at present, information is limited about how to design nurses’ work and work environment to make them safer for patients.

Information on Nurses’ Work

As noted in Chapter 3, because data are not collected routinely on the activities performed by nurses and how nurses spend their time, it is difficult to measure the effects of interventions aimed at redesigning care to improve safety or efficiency or to understand the implications of policy changes for nursing practice. Research is needed on how to collect information on nurses’ work on an ongoing basis.

Better Information on Nursing-Related Errors

Because medication errors constitute a large share of all health care errors, medication administration by nurses has received a great deal of attention from researchers and system designers aiming to develop safer

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