contact with all health care personnel providing care to the patient—across multiple units, divisions, services, institutions, and providers constituting the health care delivery system—and are able to detect and take action to fill gaps in patient care in order to protect the patient.

Distinguished physician and author Lewis Thomas, former Dean of the Yale and New York University medical schools and chief executive officer of the Sloan-Kettering Institute in New York City at the time of his death in 1993, well describes this integrating and coordinating function of nurses in The Youngest Science: Notes of a Medicine Watcher:

One thing the nurses do is to hold the place together. It is an astonishment, which every patient feels from time to time, observing the affairs of a large, complex hospital from the vantage point of his bed, that the whole institution doesn’t fly to pieces. A hospital operates by the constant interplay of powerful forces pulling away at each other in different directions, each force essential for getting necessary things done, but always at odds with each other…. My discovery, as a patient … is that the institution is held together, glued together, enabled to function as an organism, by the nurses and nobody else. (Thomas, 1983:66–67)


Because nurses carry out the responsibilities described above, they potentially are well positioned to observe and influence how the health care system functions across all aspects of patient care, and thereby to detect and address threats to patient safety. However, nurses’ work and work environments have changed over the last two decades, and these changes have been cited as having implications for patient safety.

More Acutely Ill Patients

Nurses, health care industry associations, and numerous other entities have observed that hospital and nursing home patients are more severely ill than in the recent past. Although the truth of this observation is widely accepted, its extent and its implications for nursing are difficult to determine. First, there is no standard method used across hospitals to measure the severity of illness of all hospital patients. Although many hospitals use patient acuity systems to estimate the amount of nursing care their patients will require, those systems are not standardized, and there is no external reporting to produce national trend data. Second, where other severity-of-illness measurements are collected (i.e., for Medicare patients), the severity of a patient’s medical illness does not necessarily correlate with the level of nursing care that a patient requires. For example, a patient with pneumonia

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