Index

A

AACCN. See American Association of Critical Care Nurses

AAMC. See Association of American Medical Colleges

Accreditation Council for Graduate Medical Education (ACGME), 391, 394–395

ACGME. See Accreditation Council for Graduate Medical Education

Acquisition of knowledge and skills

decision support at the point of care delivery, 209–212

individualized training, 208

preceptorships and residencies for new nurses, 207–208

simulation techniques, 208–209, 346, 372

strategies to support nursing staff in ongoing, 207–212

“Active and latent errors,” 29n

Activities of daily living (ADLs), 95, 166, 170

Acuity, assessing patient, 184–185

Acuity-adaptable rooms, 263–264

“Acuity creep,” 187

Acute care hospital staffing, 171–178

intensive care units, 172, 175–176

medical-surgical units, 172, 176–178

numbers of nurses essential to patient safety, 164–166

overall hospital staffing, 173–175

ranges of RN-to-patient staffing ratios, 172

step-down units, 172, 178

Acutely ill patients, increasing numbers of, 37–39

Ad Hoc Advisory Committee on Emergency Services, 394

ADEs. See Adverse drug events

ADLs. See Activities of daily living

Adverse drug events (ADEs), 242, 321–322

affected by nurse fatigue, 6

causes of, 239–240

intercepted by nurses, 3

remedies for, 240–242

Adverse events

from HCO leaders’ decisions on patient safety, identifying and minimizing potential, 8, 146

preventable, 25

Aerospace industry, work hour regulation in, 413–415

Agency for Healthcare Research and Quality (AHRQ), 2–3, 23, 43–44, 47, 69, 182, 187, 210, 232, 240, 308, 321, 391

Aging of the nursing workforce, 71–72

AHA. See American Hospital Association

AHCA. See American Health Care Association



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Index A AACCN. See American Association of Critical Care Nurses AAMC. See Association of American Medical Colleges Accreditation Council for Graduate Medical Education (ACGME), 391, 394–395 ACGME. See Accreditation Council for Graduate Medical Education Acquisition of knowledge and skills decision support at the point of care delivery, 209–212 individualized training, 208 preceptorships and residencies for new nurses, 207–208 simulation techniques, 208–209, 346, 372 strategies to support nursing staff in ongoing, 207–212 “Active and latent errors,” 29n Activities of daily living (ADLs), 95, 166, 170 Acuity, assessing patient, 184–185 Acuity-adaptable rooms, 263–264 “Acuity creep,” 187 Acute care hospital staffing, 171–178 intensive care units, 172, 175–176 medical-surgical units, 172, 176–178 numbers of nurses essential to patient safety, 164–166 overall hospital staffing, 173–175 ranges of RN-to-patient staffing ratios, 172 step-down units, 172, 178 Acutely ill patients, increasing numbers of, 37–39 Ad Hoc Advisory Committee on Emergency Services, 394 ADEs. See Adverse drug events ADLs. See Activities of daily living Adverse drug events (ADEs), 242, 321–322 affected by nurse fatigue, 6 causes of, 239–240 intercepted by nurses, 3 remedies for, 240–242 Adverse events from HCO leaders’ decisions on patient safety, identifying and minimizing potential, 8, 146 preventable, 25 Aerospace industry, work hour regulation in, 413–415 Agency for Healthcare Research and Quality (AHRQ), 2–3, 23, 43–44, 47, 69, 182, 187, 210, 232, 240, 308, 321, 391 Aging of the nursing workforce, 71–72 AHA. See American Hospital Association AHCA. See American Health Care Association

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses AHRQ. See Agency for Healthcare Research and Quality Air Commerce Act, 411 Air Transport Association of America, 412 Aircraft carriers, communication redundancies on, 262 Alerts, generating when standards of care are not being followed, 265 AMA. See American Medical Association American Academy of Nursing, 209 American Association of Colleges of Nursing, 207 American Association of Critical Care Nurses (AACCN), 269, 390 American College of Critical Care Medicine, 2, 93 American Health Care Association (AHCA), 43, 69, 86, 320 American Hospital Association (AHA), 132, 174, 178, 204, 243 Annual Survey of Hospitals, 200 American Institute of Architects, 269 American Medical Association (AMA), 395 American Medical Student Association, 395 American Nurses Association (ANA), 88, 148, 232 American Nurses’ Credentialing Center (ANCC), 148, 150 American Organization of Nurse Executives (AONE), 86, 120, 133–134 American Society for Training and Development (ASTD), 206–208 American Society of Health Systems Pharmacists, 241 Ames Fatigue Countermeasures Group, 415 ANA. See American Nurses Association ANCC. See American Nurses’ Credentialing Center Annual Survey of Hospitals, 200 Anticipatory failure analysis, 257 AONE. See American Organization of Nurse Executives Apollo 13, 414–415 Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, 167 Phase II Final Report, 10, 182–183 ASRS. See Aviation Safety Reporting System Assessment continual, of staffing methodologies and their relationship to patient safety, 193 of existing knowledge culture within organizations, 129–130 of patient acuity level, 184–185 of patients, 32, 34 Assistance in knowledge and skill acquisition, need to strengthen ongoing, 201–206 Association of American Medical Colleges (AAMC), 391, 395 ASTD. See American Society for Training and Development Asynchronous messaging, 266 Attention, short-lived, 141–142 Attribution errors, fundamental, 27 Australia, error rates in, 27 “Authority gradient,” 289 Automation of record systems, 246, 266 use of, 246–247 Aviation Human Factors Team, 412 Aviation industry, work hour regulation in, 410–413 Aviation Safety Reporting System (ASRS), 412 B Back-up systems, instilling, 262–263 Balanced Budget Act of 1997, 85 Bar code medication administration (BCMA) assistance device, 241–242, 267 Barriers to effective safety cultures, 299–303 litigation and regulatory barriers, 300–303 nursing cultures fostering unrealistic expectations of clinical perfection, 299–300 Barriers to effective team development and performance, 366–368 BCMA. See Bar code medication administration assistance device Bell, Bertand, 394 “Bell Regulations,” 393–394 Benchmarking organizational safety cultures, 308–309 Benchmarking training practices, in other industries and health care, 206–207 Benefits in addition to patient safety, 316–322 better retention of nurses and other health care workers in short supply, 317–319

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses increased patient satisfaction, 319 potential financial advantages, 319–322 Benefits of RN surveillance, 92–93 Blame assignment of, 27–28, 301–302 going beyond, 293 Boards of directors, recommendations for, 8, 14 Boston Globe, 302 Bronson Methodist Hospital, 253 Budgetary expenditures, recommendations regarding, 11–12 “Buffer stock” concept, 263 Bureau of Labor Statistics, 74 Burns, James, 109–111 C California HealthCare Foundation, 197 California hospital nurse-to-patient ratios, means, medians, and quartiles, 178 California Nurses Association, 386 California Nursing Home Search (Calnhs), 197 California Nursing Outcomes Coalition (CalNOC), 81, 171 California Office of Statewide Health Planning and Development (OSHPD), 174, 176, 178 Calnhs. See California Nursing Home Search CalNOC. See California Nursing Outcomes Coalition Campbell Collaboration, 113 Cardiac Comprehensive Critical Care Unit, 269 Care delivered, versus care needed, 186 Care delivery changes in approaches to, 79–80 decision support at the point of, 209–212 Carnegie Mellon University, 151 Case mix index (CMI), 38 CDC. See U.S. Centers for Disease Control and Prevention CDSSs. See Clinical decision support systems Center for Health Design, 255 Center for Health Management Research (CHMR), 154–155 Center for Health Services Research, 151 Center for Shared Learning. See U.S. Centers for Disease Control and Prevention Center of Outcomes Research and Clinical Effectiveness, 305 Centers for Medicare and Medicaid Services (CMS), 167, 170, 194, 197–199, 245 Certified nursing aides (CNAs), 68, 96, 168 Challenger space shuttle explosion, 231, 367, 387, 414 Change management factors, 118–121 mechanisms for feedback, measurement, and redesign, 120 ongoing communication, 118–119 poor, 139–142 sustained attention, 120–121 training, 119–120 worker involvement, 121, 142 Change Program, 119 Changes in approaches to care delivery, 79–80 in deployment of nursing personnel, 41–42 in hospital admission practices, 187–188 in hospital workload, 80–82 Changes in nursing leadership concerns about, 132–136 potential loss of a common voice for nursing, 133–135 weakening of clinical leadership, 135–136 Chicago Tribune, 46 Chief nurse executives (CNEs), 123–124, 133, 147–150 Chief nurse officers (CNOs), 132–135 CHMR. See Center for Health Management Research CINAHL. See Cumulative Index to Nursing and Allied Health Literature Circadian rhythms, 228, 236, 385, 387, 397 Clarian Health Partners, 267–269 Clinical decision support systems (CDSSs), computer-supported, 210–211 Clinical nursing leadership reduction at multiple levels, 4 weakening of, 135–136 Clinical pathways, decision support at the point of care delivery, 209–210 Clinical perfection, nursing cultures fostering unrealistic expectations of, 299–300

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Clockwise shift rotations, 229 Cluster form patient care units, 250 CMI. See Case mix index CMS. See Centers for Medicare and Medicaid Services CNAs. See Certified nursing aides CNEs. See Chief nurse executives CNOs. See Chief nurse officers Cochrane Library, 357–358 Collaboration building and nurturing, 216–217 commitment of resources to build nurse expertise, 216 design of work and workspace to facilitate collaboration, 216–217 human resource policies, 217 interdisciplinary practice mechanisms, 217 leadership modeling of collaborative behaviors, 216 training, 217 Collaborative characteristics, 214–215 conflict management, 214–215 effective communication, 214 shared decision making, 214 shared understanding of goals and roles, 214 Collaborative models of care achieving effective collaboration among groups of health care practitioners with differing characteristics, 324 effect of crew resource management principles and other non-health-related strategies in achieving collaboration and error reduction, 325 effect of environmental influences on team performance, 324 fostering more productive interpersonal interactions across the multiple interactions of health care workers, 325 interpersonal and group interaction processes contributing to effective collaboration and delivery of safe care, 324 research needed on, 324–325 Collaborative Research Centers, 155 Commercial Mariner Endurance Management System, 407 Commission on Nursing, 132 Commitment needed to create a culture of safety good safety performance seen as an organizational goal, 296–298 from leadership, 287–288 long-term, 295–299 safety performance seen as dynamic and always amenable to improvement, 298–299 safety seen as an external requirement imposed by governmental or other regulatory bodies, 296 Committee on the Work Environment for Nurses and Patient Safety, 2, 24 Communication in actively managing the process of change, 118–119 characteristic of collaboration, 214 hierarchical, 289 inadequate, 140 in ongoing vigilance, 289–290 Communication technology, poor, 253–254 Community-based organizations, nursing staff in, 84–85 Compensating for hand-offs, 263–264 Complications, postoperative, and staffing levels, 176 Computer-supported clinical decision support systems, 210–211 Confidential error reporting, 292–293 Conflict management, characteristic of collaboration, 214–215 Congress, recommendations for, 15, 287 Constraint, 263 of improvisation in ongoing vigilance, 290 Construction of work environments more conducive to patient safety, 18, 55 in the Toyota Production System, 126 Consumer-driven responses to evidence on staffing and patient safety, 196–201 need for more accurate and reliable staffing data to inform these efforts and research on staffing, 198–201 report cards on performance, 196–198 Consumers of the “production process” in health care, vulnerability of, 62 Continental form patient care units, 250 “Contingent workers,” RNs being employed as, 74–76

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Continuing education programs, hospitals scaling back, 5 Coordination of care and services, from multiple providers, 36–37 Core unit space, 249 Corning International, 368–369 Corridor form patient care units, 250 Courtyard form patient care units, 250 CPS. See Current Population Survey Creating effective teams and collaborative work relationships in the workplace, 366–375 barriers to effective team development and performance, 366–368 facilitators of effective team development and performance, 368–370 methods for measuring the safe care delivery practices of work teams and collaborative groups, 373–375 strategies for developing and maintaining effective work teams and partnerships, 370–373 Creating learning organizations, 124–131 actively managing the learning process, 125–128 time required to create a learning organization, 128–131 Creating trust, 115–118, 137–139, 149, 214, 292 Crew Endurance Management System, 407 Crew resource management (CRM), 365–366, 376 effect in achieving collaboration and error reduction, 325 Critical care nurses, relation to patient outcomes, 2 Critical role of nurses in patient safety, 2–3 CRM. See Crew resource management Crossing the Quality Chasm: A New Health System for the 21st Century, 15–18, 24, 44, 48, 124, 201–202, 209–210, 226, 316 as a framework for building patient safety defenses into nurses’ work environments, 53–55 Cruciform patient care units, 250 Cultures of safety with all employees empowered and engaged in ongoing vigilance, 288–291 barriers from nursing and external sources, 299–303 benchmarking organizational, 308–309 commitment of leadership to, 287–288 creating and sustaining, 14–15, 286–311 designing uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, 15, 310 essential elements of effective, 287–295 legislating peer review protection for reporting of patient safety and quality improvement data, 15, 310 need for a long-term commitment to create, 295–299 need for all HCOs to measure their progress in creating, 307–309 organizational learning from errors and near misses, 292–295 progress in creating, 303–307 recommendations for, 14–15, 309–310 Cumulative Index to Nursing and Allied Health Literature (CINAHL), 144 Current Population Survey (CPS), 74 D Daily patient volume, incorporating admissions, discharges, and “less than 24-hour” patients into estimates of, 189 Decision makers, role in an evidence-based model for safety defenses in work environments, 57 Decision making characteristic of collaboration, 214 in magnet hospitals, workers involved in, 149–150 nonhierarchical, in ongoing vigilance, 290 work design and work flow, 121–124, 143 Decision support clinical pathways, 209–210 computer-supported clinical decision support systems, 210–211 organizational support for ongoing, 17, 315 at the point of care delivery, 209–212 technology for, 5

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Decision tree, for determining culpability for unsafe acts, 301, 304 Defects, in the hospital environment, 259 Defenses. See Patient safety defenses Delivery modes in health care, implications for patient safety defenses, 62 Demand elasticity, to accommodate unpredicted variations in patient volume and/or acuity, 190–193 Demographic characteristics of the nursing workforce, 70–76 not yet fully reflecting the racial and ethnic diversity of the U.S. population, 72–73 older and more rapidly aging, 71–72 predominantly female, 70–71 RNs employed as “contingent workers,” 74–76 salaries that might be increasing for hospital RNs, while many NAs live at or below poverty level, 73–74 Deployment of nursing personnel to care for patients, changes in, 41–42 Desert Storm, 399 Design of patient care units, 248–250 common designs, 250–251 core unit space, 249 hallway, 249–250 nursing station, 249 patient rooms, 248–249 Design of work hours, 227–238 data on nurse work hours, 233–236 effect of fatigue from shift work and extended work hours on work performance, 227–232 evidence on nurse work hours and the commission of errors, 232–233 responses to the evidence, 236–238 Design of work processes and workspace, 239–277 in building and nurturing collaboration, 216–217 designing work processes and workspaces to enhance safety and efficiency, 255–256 documentation and paperwork, 244–248 effect of workspace physical design on efficiency and safety, 248–255 inherent risks to patient safety in some nursing work processes, 239–243 reduced patient safety due to inefficient nurse work processes, 243–248 work and error analysis techniques, 256–267 workspace design for safety and efficiency, 267–269, 276–277 DHHS. See U.S. Department of Health and Human Services Diablo Canyon Nuclear Power Plant, 206, 291 Diagnosis-related group (DRG), 38n Direct-care nursing staff dealing with documentation demands, 100 educating patients and families, 97 helping patients compensate for loss of functioning, 95–96 integrating hands-on patient care, 97–100 involving in selecting, modifying, and evaluating staffing methods, 189–190 monitoring of patient status (surveillance), 91–94 physiologic therapy, 94–95 providing emotional support, 96–97 providing patient care, 90–101 RNs supervising other nursing personnel, 100–101 Direct patient care, versus indirect, 36, 100n, 237 Distractions decreasing, 261–262 inefficiencies created by, 6–7 Diversity of tasks and tools in health care, implications for patient safety defenses, 61 DMAIC approach to error reduction, 258–259 Documentation and paperwork, 45–46, 100, 244–248 multiple sources of demands for, 245 need for internal and external solutions to, 245–248 nurses’ time spent documenting patient care activities, 6, 244–245 Double corridor patient care units, 250–251 Double shifts, 44 DRG. See Diagnosis-related group Duplex patient care units, 250

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses E EBMCs. See Evidence-based management collaboratives ECMO. See Extra-corporeal membrane oxygenation Educating patients and families, by direct-care nursing staff, 97 Education, 66–68 for LPNs/LVNs, 67 for NAs, 67–68 for RNs, 66–67 Edward Hospital (EH), 137–138 Effectiveness of nurse staffing practices with respect to patient safety, performing ongoing evaluation of, 10–11, 194 Efficiency, balancing with reliability, 114–115 EH. See Edward Hospital Electronic information databases, 266 Elephant, fable of blind men and, 56–57 Emotional support provided by direct-care nursing staff, 96–97 time required for, 98–99 Empowerment, 122–123, 363 Environmental factors, 256 effect on team performance, 324 threatening patient safety, 46–47 Ergonomics, 276 Error analysis techniques, 256–267 anticipatory failure analysis, 257 avoiding reliance on individual vigilance, 263 avoiding reliance on individual worker memory, 261 decreasing interruptions, distractions, and interferences, 261–262 directly involving workers throughout the design process, 260 improving information access, 264–266 instilling redundancy and back-up systems, 262–263 “LEAN” operations, 256–258, 269–275 paying ongoing attention to work design, 266–267 reducing and compensating for hand-offs, 263–264 remaining alert to the limitations of and risks created by technology, 266–267 root-cause analysis, 257 simplifying and standardizing common work procedures and equipment, 260–261 using constraint and forcing functions, 263 work design principles, 258–260 work sampling, 256–257 Error reporting confidential, 292–293 overall features of an effective system for, 294–295 Errors creating serious health consequences, 1, 25, 46, 183–184 better information needed on nursing-related, 322–323 causes of, 27–31 containing the effects of, 260 detecting early, 260 discovering, 30, 63, 292 eliminating, 259 evidence on nurse work hours and the commission of, 232–233 fair and just responses to, 292–293 hospitalized Americans dying from, 26 human contributions to within each production component, 59 numbers of, 24–27 reducing occurrence of, 259 theories of team behavior and, 344–348 Estimates of daily patient volume, incorporating admissions, discharges, and “less than 24-hour” patients into, 189 Ethnic diversity of the U.S. population, nursing workforce not yet fully reflective of, 72–73 Evaluation of effectiveness of nurse staffing practices with respect to patient safety, performing ongoing, 10–11, 194 Evaluation of patients, 32 Event investigation in health care, implications for patient safety defenses, 63 Evidence-based management, 113 decision makers in, 57 defenses in, 58 leadership and, 16, 314 line management in, 57 model for safety defenses in work environments, 56–61

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses preconditions of, 57 productive activities in, 58 supporting HCOs in identification and adoption of, 9, 155 Evidence-based management collaboratives (EBMCs), 153–154 Center for Health Management Research, 154–155 used to stimulate further uptake, 153–155 Evidence-based management in nurses’ work environments, 147–153 concerns about changes in nursing leadership, 132–136 increased emphasis on production efficiency, 136–137 limited involvement in decision making pertaining to work design and work flow, 143 limited knowledge management, 144–146 magnet hospitals, 147–150, 207 Pittsburgh Regional Healthcare Initiative, 151–152 poor change management, 139–142 recommendations to promote evidence-based management practices, 146–147 uneven application of, 131–147 weakened trust, 137–139 Wellspring Innovative Solutions, Inc., 152–153, 359–360 Expectations of clinical perfection, nursing cultures fostering unrealistic, 299–300 Experience and expertise, variations in among members of the nursing workforce, 66–70 Experimentation, systematic, to generate new knowledge internally, 125 Expert Advisory Panel on Patient Safety System Design, 294 Extended work hours, 229–232 External agencies, using nursing staff from, 193 External requirement imposed by governmental or other regulatory bodies, safety performance as, 296 Extra-corporeal membrane oxygenation (ECMO), 33 Exxon Valdez oil spill, 231, 387, 406 F FAA. See Federal Aviation Administration Facilitators of effective team development and performance, 368–370 organization/systems-related factors, 369–370 team-related factors, 369 Failure modes and effects analysis (FMEA), 257 Failures active, 29 to rescue, 171 Failures to follow management practices necessary for safety, 3–4 lessening impact of nurses’ input in patient care, 4 reduction of clinical nursing leadership at multiple levels, 4 widespread loss of trust in hospital administration among nursing staff, 4 Fair Labor Act of 1945, 409 Fair responses to reported errors, 292–293 Falklands conflict, 399 Fatigue affecting work performance, 6, 227–232, 384–435 countermeasures programs, 415–417 effects of, 384–388 from extended work hours, 229–232 from shift work, 228–229 strategies to help night shift workers compensate, 324 FCTs. See Flight control teams FDA. See U.S. Food and Drug Administration Federal agencies, recommendations for, 19 Federal Aviation Administration (FAA), 293, 375, 411 Feedback in actively managing the process of change, 120 lack of, 141 Financial factors likely potential for advantages, 319–322 pressures to curtail nurse training, 5 Firefighters, work hour regulation for, 396–397 Fitness for Duty Program, 402 Flight control teams (FCTs), 413 “Float nurses,” 192, 212–213 FMEA. See Failure modes and effects analysis

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Foote, Shelby, 114 Forcing functions, 263 Ford Pinto recall, 367 Functioning, direct-care nursing staff helping patients compensate for loss of, 95–96 G “Gaming” the system, incentives for created by multiple purposes, 186–187 GAO. See U.S. General Accounting Office GEM. See Geriatric evaluation and management interdisciplinary teams General Social Survey, 88 Geriatric and other team interventions, effectiveness of, 354–356 Geriatric evaluation and management (GEM) interdisciplinary teams, 355 Good Samaritan Hospital (GSH), 305–306 Center of Outcomes Research and Clinical Effectiveness, 305 Governing boards, that focus on safety, 16, 314 Governmental bodies, safety performance as external requirement imposed by, 296 Great Britain, error rates in, 26 Group interaction processes, contributing to effective collaboration and delivery of safe care, 324 GSH. See Good Samaritan Hospital H Hallways, 249–250 Hand-offs, 263–264 risks of, 264 Handwashing, 242–243 addressing first among work design initiatives, 13, 276 Harvard Business School, 144 HCOs. See Health care organizations “Healing environments,” cost savings from, 254 Health care elements having implications for patient safety defenses, 61–64 diversity of tasks and tools, 61 event investigation, 63 greater risk associated with health care activities, 61–62 mode of delivering health care, 62 uncertainty of the knowledge base, 63 vulnerability of the consumers of the “production process,” 62 Health care errors. See Errors creating serious health consequences Health Care Financing Administration, 90n Health care organizations (HCOs), 1, 70, 108–109, 162 need to measure progress in creating cultures of safety, 307–309 not waiting to act, 313–315 recommendations for, 8–15 Health care providers with differing characteristics, achieving effective collaboration among groups of, 324 nurses as the largest segment of, 31–32 Health care providers’ work schedules, 388–396 nurses, 388–391 physicians, 391–396 work hour limitations for, 418 Health care work groups and performance outcomes, 352–363 effectiveness of geriatric and other team interventions, 354–356 effectiveness of interdisciplinary geriatric teams, 353–354 effectiveness of interdisciplinary teams, 356–357 improving collaboration between the nursing and medical professions, 357–360 innovative models of health care delivery, 360 team delivery of care in areas of chronic illness and rehabilitation, 353 teams and patient safety outcomes, 360–363 Health Professions Education: A Bridge to Quality, 201n Health Resources and Services Administration (HRSA), 87 Hierarchical communication, 289 High-involvement work systems, 122 Home health nurses, 84–85 assessment instruments and tools used by, 34

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Hospital administration, widespread loss of trust in among nursing staff, 4 Hospital admission practices, methods for predicting patient volume failing to keep pace with changes in, 187–188 Hospital Patient Perspectives on Care instrument, 198 Hospital staffing, 76–82 in acute care settings, 173–175 changes in workload, 80–82 data needed on, 200–201 work hours of nurses, 234–235 Hospital Survey on Patient Safety, 308 Hospitals, 76–82 changes in approaches to care delivery, 79–80 fewer hospitals, fewer inpatient beds, and fewer (but more acutely ill) inpatients, 78–79 indirect costs from patient transfers, 252 infections acquired in, 242 magnet, 147–150, 207 recommendations for, 10–11 report cards needed, 197–198 shorter stays in, 39–40 See also Acute care hospital staffing Hours of Service Act, 404, 408–410 House Energy and Commerce Committee, 395 House Subcommittee on Health, 395 HRSA. See Health Resources and Services Administration Human Error, 29n, 57 Human factors engineering, 276 Human resource policies, for building and nurturing collaboration, 217 Hygienic hand rubs, 243 I ICC. See Interstate Commerce Commission ICUs. See Intensive care units IDAs. See Intelligent decision aids IHC. See Intermountain Health Care Implementation considerations, 15–20, 312–327 health care organizations and other parties not waiting to act, 313–315 for key recommendations from prior reports, 18, 54 likely benefits in addition to patient safety, 316–322 multiple, mutually reinforcing safeguards needed, 315–316 piecemeal approaches unlikely to succeed, 18 recommendations built on two prior IOM reports, 15–18, 325 Improvement safety performance as always amenable to, 298–299 of work in the Toyota Production System, 127 In-service training programs hospitals scaling back, 5 shortcomings of, 205 Inaccurate workload estimates, for various patient classification levels, 185–186 Incentives, in ongoing vigilance, 291 Incident decision tree, for determining the culpability for unsafe acts, 301, 304 Individual clinical competence, a necessary precursor to collaboration, 213–214 Individualized training, 208 Individuals performing the work avoiding reliance on memory of, 261 avoiding reliance on vigilance of, 263 characteristics of, 255 Industry/University Collaborative Research Centers, 155 “Inevitable availability,” of nurses, 36 Informatics experts, recommendations for, 13 Information access asynchronous messaging, 266 data that are organized and legible, 265 electronic databases, 266 generating alerts, reminders, or suggestions when standards of care are not being followed, 265 improving, 264–266 support for ongoing knowledge acquisition, 265 Innovative models, of health care delivery, 360 Inpatients, fewer beds for, with fewer but more acutely ill patients, 78–79 Institute for Safe Medication Practices, 240–241, 303 Institute of Medicine (IOM), 1–2, 15, 18, 23–24, 26, 44, 47, 53–55, 57, 73, 86, 124, 167, 183, 201, 226, 287, 316

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Integration of hands-on patient care by direct-care nursing staff, 97–100 from multiple providers, 36–37 Intelligent decision aids (IDAs), 373 Intensive care units (ICUs), 75, 164–165 acute care hospital staffing levels in, 172, 175–176 changes in workload in, 81 collaboration within, 214, 351–352 patient monitoring in, 33 recommendations for, 11, 194–195 Interdisciplinary collaboration and patient safety, 212–218, 341–383 building and nurturing collaboration, 216–217 characteristics of collaboration, 214–215 creating effective teams and collaborative work relationships in the workplace, 366–375 hallmarks of effective interdisciplinary collaboration, 213–215 inconsistent collaboration between nursing staff and other health care providers, 215–216 mechanisms that promote, 17, 315 necessary precursors to collaboration, 213–214 need for further research, 375–378 supporting by adoption of specific mechanisms and training in collaboration, 12, 217 teams and performance outcomes, 342–366 Interdisciplinary teams building and nurturing collaboration within, 217 effectiveness of, 356–357 geriatric, 353–354 Interference decreasing, 261–262 sensory, 254–255 Intermountain Health Care (IHC), 264–266 Internal staffing practices by HCOs, 184–196 methods for predicting patient volume failing to keep pace with changes in hospital admission practices, 187–188 problems in applying widely used tools to predict hospital staffing, 184–187 International Atomic Energy Agency, 76, 206, 295 International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers, 408 International Institute for Management Development, Change Program, 119 International Maritime Organization, 408 Interpersonal interactions, 377 across the multiple interactions of health care workers, fostering more productive, 325 contributing to effective collaboration and delivery of safe care, 324 Interruptions, 45 decreasing, 261–262 inefficiencies created by, 6–7 Interstate Commerce Commission (ICC), 408 Inventory, excess, in the hospital environment, 259 Involvement. See Worker involvement IOM. See Institute of Medicine J JCAHO. See Joint Commission on the Accreditation of Healthcare Organizations Johnson Space Center, 413 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), 47, 55, 184–185, 193, 203–204, 247, 257, 302–303, 317, 320 K Kaiser Permanente, 306–307 National Patient Safety Advisory Board, 307 Patient Safety Plan, 306 Kennedy Space Center, 413 Knowledge support for ongoing acquisition of, 265 taking advantage of all sources of, 125 transferring quickly and efficiently throughout the organization, 125–128 Knowledge and skills decision support at the point of care delivery, 209–212 individualized training, 208

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses where nurses work, 76–89 who is doing the work of nursing, 65–76 wide variety of health care settings for nursing staff, 76–86 workplace characteristics that hinder safe nursing care, 101 Nursing workload, effect of patient care unit design on, 251 O OASIS. See Outcome and Assessment Information Set “Observation only” patients, 188 Occupational Health and Safety Administration (OSHA), 395 Office of Nuclear Reactor Regulation, Division of Licensing, 401 Office of Statewide Health Planning and Development (OSHPD), for California, 174, 176, 178 Oil Pollution Act of 1990, 406–407 Older nursing workforce, 71–72 OLOL. See Our Lady of the Lake Regional Medical Center OMAHA system, 46 On-line Survey and Certification Report (OSCAR), 169, 199 “On-time” staffing, to accommodate unpredicted variations in patient volume and/or acuity, 190–193 Ongoing in-service training programs, hospitals scaling back, 5 Ongoing learning, organizational support for, 17, 315 Open form patient care units, 250 Organization/systems-related factors, facilitating effective team development and performance, 369–370 Organizational cultures continuously strengthening patient safety, 17, 315 high-reliability, 56, 191, 291, 348 hindering the reporting and prevention of errors, 7 promoting reporting, analysis, and prevention of errors, 7 and team performance, 348–352 threatening patient safety, 19, 48, 60 Organizational goals, safety performance as, 296–298 Organizational leaders, recommendations for, 9, 13 Organizational learning from errors and near misses, 292–295 confidential error reporting, 292–293 data analysis and feedback, 294 fair and just responses to reported errors, 292–293 overall features of an effective error-reporting system, 294–295 reporting near misses as well as errors, 293–294 Organizations assessing the existing knowledge culture within, 129–130 characteristics of, 256 transferring knowledge quickly and efficiently throughout, 125–128 Organized data, 265 Orientation programs hospitals scaling back, 5 for newly licensed RNs, 204 OSCAR. See On-line Survey and Certification Report OSHA. See Occupational Health and Safety Administration OSHPD. See California Office of Statewide Health Planning and Development Our Lady of the Lake (OLOL) Regional Medical Center, 211 Outcome and Assessment Information Set (OASIS), 35, 46, 245 Overtime and Staffing Problems in the Commercial Nuclear Power Industry, 402 Overtime hours, 229–232 mandatory, 234, 237 P Patient acuity level assessing, 184–185 PCSs lacking desired sensitivity to variations in, 185 standardizing approach to measuring, 323 Patient and Physician Safety Act of 2001, 395

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Patient care delivered versus needed, 186 direct versus indirect, 36 lessening impact of nurses’ input in, 4 Patient care unit designs, 248–251 corridor or continental form, 250 courtyard, 250 cruciform or cluster, 250 duplex or nuffield, 250 effect on nursing workload, 251 racetrack or double corridor, 250–251 radial, 250 simple open or nightingale form, 250 triangle, 250–251 Patient classification systems (PCSs), 184–187, 189–190, 193 inaccurate and unreliable workload estimates in various, 185–186 lacking desired sensitivity to variations in patient acuity level, 185 time consumed by, 187 Patient management and oversight responsibilities, 377–378 Patient outcomes, causal relationship with staffing levels, 169–171 Patient rooms, 248–249 Patient safety continuing to be threatened, 1–2 employing management structures and processes throughout the organization that focus on, 8–9, 147 key aspects of nurses’ work environment that impact, 2 numbers of health care errors, 24–27 nursing inseparably linked to, 3–7, 23–52 potential improvements in health care working conditions that would likely increase, 2 potential workspace design elements for, 269 reasons health care errors occur, 27–31 research needed to further increase, 18–20, 322–325 transforming nurses’ work environments essential to, 47–52 See also Risk factors in health care; Threats to patient safety Patient safety defenses, 16–17, 314–315 adequate staffing, 16–17, 315 building on To Err Is Human and Crossing the Quality Chasm, 53–55 effective nursing leadership, 16, 314 an evidence-based model for safety defenses in work environments, 56–61 failure of, 28 framework for building into nurses’ work environments, 53–64 governing boards that focus on safety, 16, 314 leadership and evidence-based management structures and processes, 16, 314 mechanisms that promote interdisciplinary collaboration, 17, 315 the need for bundles of multiple, mutually reinforcing patient safety defenses, 55–56 organizational culture that continuously strengthens patient safety, 17, 315 organizational support for ongoing learning and decision support, 17, 315 role in an evidence-based model for safety defenses in work environments, 58 unique features of health care that have implications for patient safety defenses, 61–64 work design that promotes safety, 17, 315 See also Threats to patient safety Patient Safety Improvement Initiative, 292 Patient Safety Plan, at Kaiser Permanente, 306 Patient satisfaction, likely increases in, 319 Patient transfers, 251–253 impact on patient length of stay, 252–253 indirect hospital costs, 252 labor cost, 252 time elapsed, 252 Patients frequent turnover of, 42 impact of patient transfers on length of stay, 252–253 monitoring, 32 monitoring in an intensive care unit, 33 “observation only,” 188

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses PCSs. See Patient classification systems Performance Maintenance during Continuous Flight: A Guide for Flight Surgeons, 399 Performance outcomes degraded by fatigue, 6 health care work groups and, 352–363 non-health-related work groups and, 363–366 Performance-shaping factors (PSFs), 345 Philanthropic organizations, recommendations for, 9 Physicians errors by, 35–36 work schedules of, 391–396 See also Relationships between nurses and physicians Physiologic therapy, by direct-care nursing staff, 94–95 Pittsburgh Regional Healthcare Initiative (PRHI), 151–152 as a model of evidence-based management in nurses’ work environments, 151–152 Point-of-use storage, 258 Police, work hour regulation for, 396–397 Polysomnography studies, 415 Poor change management, 139–142 inadequate communication, 140 insufficient worker training, 140–141 lack of measurement and feedback, 141 low worker involvement in developing change initiatives, 142 short-lived attention, 141–142 “Positive relationships,” between nurses and physicians, 215–216 Postoperative complications, and staffing levels, 176 “Power weekends,” 392 PPS. See Prospective payment system Preceptorships, for new nurses, 207–208 Precursors to collaboration, 213–214 individual clinical competence, 213–214 mutual trust and respect, 214 Predicting hospital staffing inaccurate and unreliable workload estimates for various patient classification levels, 185–186 incentives for gaming created by multiple purposes, 186–187 PCSs lacking desired sensitivity to variations in patient acuity level, 185 problems in applying widely used tools for, 184–187 time consumed by PCSs, 187 Preventable adverse events, 25 PRHI. See Pittsburgh Regional Healthcare Initiative Private foundations, recommendations for, 19 Problems with recruitment and retention of nursing staff across clinical settings, 86–89 nationwide nursing shortage, 86–87 working conditions that discourage nursing staff from remaining in the workforce, 87–89 Process inefficiency, in the hospital environment, 259 Production efficiency, increased emphasis on, 136–137 Production factors, 58 decision makers, 58 defenses, 58 line management, 58 preconditions, 58 productive activities, 58 “Production process” in health care, vulnerability of the consumers of, 62 Productive activities, role in an evidence-based model for safety defenses in work environments, 58 Professional associations, recommendations for, 9 Progress in creating cultures of safety, 303–307 benchmarking organizational safety culture, 308–309 Good Samaritan Hospital, 305–306 Kaiser Permanente, 306–307 need for all HCOs to measure, 307–309 Prospective payment system (PPS), 38 PSFs. See Performance-shaping factors Public Citizen, 395 Public health agencies, nursing staff in, 85–86 Public service providers, 396–403 military personnel, 397–400 nuclear power plant workers, 400–403 police and firefighters, 396–397 Purdue University, 151

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Q Quality control, in the hospital environment, 259 Quality Interagency Coordination Task Force, 308 R Racetrack form patient care units, 250–251 Racial diversity of the U.S. population, nursing workforce not yet fully reflective of, 72–73 Radial patient care units, 250 Railroad employees, work hour regulation in, 403–405 RAND Corporation, 151 Reason, James, 57–61 Recommendations acquiring nurse leaders for all levels of management, 8, 136 addressing aspects of the work environment critical to patient safety that were not addressed in either prior report, 18, 55 addressing handwashing and medication administration first among work design initiatives, 13, 276 building on two prior IOM reports, 15–18, 325 collecting valid and reliable staffing and turnover data from hospitals and nursing homes, 11, 200–201 designing uniform processes across states for better distinguishing human errors from willful negligence and intentional misconduct, 15, 310 employing management structures and processes throughout the organization that focus on patient safety, 8–9, 147 employing nurse staffing practices that identify needed nurse staffing for each patient care unit per shift, 10, 194 identifying and minimizing potential adverse effects of HCO leaders’ decisions on patient safety, 8, 146 identifying strategies for safely reducing the burden of patient and work-related documentation, 13, 277 implementing specific strategies for creating and sustaining cultures of safety, 14–15, 309–310 legislating peer review protection for reporting of patient safety and quality improvement data, 15, 310 performing ongoing evaluation of effectiveness of nurse staffing practices with respect to patient safety, 10–11, 194 promoting evidence-based management practices, 146–147 providing greater detail about how HCOs can and should implement key recommendations from prior reports, 18, 54 providing nursing leadership with resources to design the nursing work environment and care processes to reduce errors, 13, 276 reducing error-producing fatigue by prohibiting nursing staff from exceeding set shift limits, 12–13, 237 supporting HCOs in identification and adoption of evidence-based management practices, 9, 155 supporting interdisciplinary collaboration by adopting specific mechanisms and training in collaboration, 12, 217 supporting nursing staff in their ongoing acquisition and maintenance of knowledge and skills, 11–12, 211–212 supporting research in specific areas to help HCOs continue to strengthen nurse work environments for patient safety, 19–20, 325 unifying work of the prior reports into a framework all HCOs can use to construct work environments more conducive to patient safety, 18, 55 updating existing minimum standards for registered and licensed nurse staffing in nursing homes, 9–10, 182–183 Recruitment and retention of nursing staff across clinical settings likely to improve, 317–319 nationwide nursing shortage, 86–87

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses problems with, 86–89 working conditions that discourage nursing staff from remaining in the workforce, 87–89 Redesigned work, 40 in actively managing the process of change, 120 Reducing errors, in the Toyota Production System, 127 Reducing hand-offs, 263–264 Redundancy, 191 instilling, 262–263 Registered nurse-to-patient staffing ratios in ICUs, 172 in medical-surgical units, 172 ranges of, 172 by shift and rural/nonrural location, in California, 177 in step-down units, 172 Registered nurses (RNs), 31n, 32, 65–66 being employed as “contingent workers,” 74–76 deaths and injuries caused by, 46 education for, 66–67 perceived shortcomings in skills levels of, 5, 204 primary employment settings of, 77 supervising other nursing personnel, 100–101 types and average length of orientation programs for newly licensed, 204 Regulatory bodies as barriers to effective safety cultures, 300–303 responding to evidence on staffing and patient safety, 180–184 safety performance viewed as external requirement imposed by, 296 Relationships between nurses and physicians improving collaboration between, 357–360 “positive,” 215–216 Remedies for adverse drug events (ADEs), 240–242 bar code medication administration, 241–242 smart infusion pumps, 242 unit dose dispensing, 241 Reminders, generating when standards of care are not being followed, 265 Report cards on performance, 196–198 hospital report cards, 197–198 nursing home report cards, 196–197 “Rescue” of patients, 32, 34–36 Research needed on collaborative models of care, 324–325, 375–378 achieving effective collaboration among groups of health care practitioners with differing characteristics, 324 application of non-health care industry training standards, 378 collaboration, communication, and other interpersonal relationship behaviors, 377 effect of crew resource management principles and other non-health-related strategies in achieving collaboration and error reduction, 325 effect of environmental influences on team performance, 324 fostering more productive interpersonal interactions across the multiple interactions of health care workers, 325 interpersonal and group interaction processes contributing to effective collaboration and delivery of safe care, 324 patient management and oversight responsibilities, 377–378 theory-testing research, 377 Research needed to further increase patient safety, 18–20, 322–325 better information on nursing-related errors, 322–323 information on nurses’ work, 322 research in specific areas to help HCOs continue to strengthen nurse work environments for patient safety, 19–20, 325 research on the effects of successive days of sustained work hours, 324 safe staffing levels at the level of different nursing units, 323–324 safer work processes and workspace design, 323 standardized approach to measuring patient acuity, 323 strategies to help night shift workers compensate for fatigue, 324

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Residencies, for new nurses, 207–208 Resources commiting to building nurse expertise, 216 poor utilization of in the hospital environment, 259 Responses to evidence on staffing and patient safety, 180–201 marketplace/consumer-driven approaches, 196–201 more effective internal staffing practices by HCOs, 184–196 regulatory approaches, 180–184 Responses to reported errors, fair and just, 292–293 Retention. See Recruitment and retention of nursing staff across clinical settings Rewards, in ongoing vigilance, 291 Risk factors in health care, 239–243 changes in deployment of nursing personnel to care for patients, 41–42 frequent patient turnover, 42 handwashing, 242–243 high staff turnover, 42–43, 319–320 implications for patient safety defenses, 61–62 increased interruptions and demands on nurses’ time, 45–46 long work hours, 43–44 medication administration, 239–242 more acutely ill patients, 37–39 nurses’ work and work environments, 37–46 rapid increases in new knowledge and technology, 44–45 redesigned work, 40 shorter hospital stays, 39–40 in work environments, 37–46 See also Threats to patient safety RNs. See Registered nurses Root-cause analysis, 257 S Safe Nursing and Patient Care Act of 2001, 236, 391 Safe staffing levels, 163–201 adequate number of nurses essential to patient safety, 163–169 explanations for causal relationship between staffing levels and patient outcomes, 169–171 at the level of different nursing units, 323–324 responding to evidence on staffing and patient safety, 180–201 variation in hospital and nursing home staffing levels, 171–180 Safeguards needed, multiple, mutually reinforcing, 315–316 Safety-conscious industries, 286 Safety defenses. See Patient safety defenses Safety performance seen as an external requirement imposed by governmental or other regulatory bodies, 296 seen as an organizational goal, 296–298 seen as dynamic and always amenable to improvement, 298–299 See also Cultures of safety Salaries, increasing for hospital RNs, while many NAs live at or below poverty level, 73–74 Scheduled shift durations, versus actual, 234–235 Schools of nursing, recommendations for, 13 Senate Committee on Finance, 395 Senate Committee on Health, Education, Labor and Pensions, 203 Sensory interference, 254–255 Shared decision making, characteristic of collaboration, 214 “Shared governance” models, 143 Shared understanding of goals and roles, characteristic of collaboration, 214 Shift work, 228–229 reducing error-producing fatigue by prohibiting nursing staff from exceeding set limits on, 12–13, 237 Simplifying common work procedures and equipment, 260–261 Simulation techniques, 208–209, 346, 372 Single-stay units, 263 Six sigma DMAIC, approach to error reduction, 258–259 Skilled nursing facilities (SNFs), 168 Skills. See Acquisition of knowledge and skills “Slack,” 191, 263 Sleep debt, 231 Sleep deprivation, effect on clinical performance, 392–393

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Slips, 261n Sloan-Kettering Institute, 37 Smart infusion pumps, 242 SNFs. See Skilled nursing facilities Society for Critical Care Medicine, 269 Solutions need for internal and external, 245–248 streamlining standards and standards compliance requirements, 247–248 use of automation, 246–247 work redesign, 245–246 SOPs. See Standard operating procedures Staff turnover high, 42–43, 319–320 minimizing, 193 Staffing, adequate, 16–17, 315 Staffing data needed, 198–201 collecting valid and reliable, 11, 200–201 from hospitals, 200–201 from nursing homes, 198–200 Staffing levels, causal relationship with patient outcomes, 169–171 Staffing principles contributing to efficiency, 188–196 continually assessing staffing methodologies and their relationship to patient safety, 193 incorporating admissions, discharges, and “less than 24-hour” patients into estimates of daily patient volume, 189 involving direct-care nursing staff in selecting, modifying, and evaluating staffing methods, 189–190 minimizing staff turnover, 193 providing for “on-time” staffing or demand elasticity to accommodate unpredicted variations in patient volume and/or acuity and resulting workload, 190–193 using nursing staff from external agencies, 193 Standard operating procedures (SOPs), 365 Standardizing common work procedures and equipment, 258, 260–261 Standards and standards compliance requirements, streamlining, 247–248 Staphylococcus aureus, outbreaks of linked to overtime, 390–391 State boards of nursing, recommendations for, 13, 287 State regulatory bodies, recommendations for, 12–13 Step-down units acute care hospital staffing levels in, 172, 178 changes in workload in, 81 Streamlined physical plant layout, 258 Stress, impact of underestimated, 371 Successive days of sustained work hours, research needed on the effects of, 324 Suggestions, generating when standards of care are not being followed, 265 Summa Health System, 246 Surveillance of patients, 32, 34–36 by direct-care nursing staff, 91–94 Sustained attention, in actively managing the process of change, 120–121 “Sustained operations,” 229 Sustained work hours, research needed on the effects of successive days of, 324 Sustaining trust, 115–118, 137–139, 149, 214, 292 Systematic experimentation, to generate new knowledge internally, 125 Systems approach, to understanding and reducing errors, 28 T Task diversity in health care, 255 implications for patient safety defenses, 61 Team functioning, 341–383 in areas of chronic illness and rehabilitation, 353 creating effective teams and collaborative work relationships in the workplace, 366–375 early theories of, 342–344 need for further research, 375–378 teams and performance outcomes, 342–366 Team nursing, 80 Team-related factors, facilitating effective team development and performance, 369 Technology, remaining alert to the limitations of and risks created by, 266–267

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Theories of work team effectiveness, 342–352 early theories of team behavior, 342–344 organizational behavior and team performance, 348–352 theories of team behavior and error, 344–348 Theory-testing research, 377 Thinking, providing time for, 130–131 Thomas, Lewis, 37 Threats to patient safety, 19, 60 management and leadership, 19, 48, 60 modeling, 372 organizational culture, 19, 48, 60 posed by work environment factors, 46–47 work processes, 19, 48, 60 workforce deployment, 19, 48, 60 Three Mile Island accident, 400, 402 Time required to create a learning organization, 128–131 aligning incentives to reinforce and facilitate uptake of knowledge management practices, 131 assessing the existing knowledge culture within the organization, 129–130 providing time for thinking, learning, and training, 130–131 See also Nurses’ time To Err Is Human: Building a Safer Health System, 1, 7, 15–16, 18, 24–28, 29n, 31, 48, 57, 226, 287, 295, 300–301, 316 as a framework for building patient safety defenses into nurses’ work environments, 53–55 Tool diversity in health care, implications for patient safety defenses, 61 Tools and technologies being used, 255 Toyota Production System (TPS), 126–127, 130, 132, 151, 258 how people work, 126 how work is constructed, 126 how work is improved and errors reduced, 127 how workers connect, 126 TPS. See Toyota Production System Training in actively managing the process of change, 119–120 in building and nurturing collaboration, 217 individualized, 208 in ongoing vigilance, 290–291 practices in other industries and health care, 206–207 providing time for, 130–131 See also Nurse training Transfers, patient, 251–253 Transformational leadership and evidence-based management, 7–9, 108–161 acquiring nurse leaders for all levels of management, 8, 136 employing management structures and processes throughout the organization that focus on patient safety, 8–9, 147 the essential precursor, 109–112 five essential management practices, 112–131 identifying and minimizing potential adverse effects of HCO leaders’ decisions on patient safety, 8, 146 models of evidence-based management in nurses’ work environments, 147–153 supporting HCOs in identification and adoption of evidence-based management practices, 9, 155 uneven application of evidence-based management practices in nurses’ work environments, 131–147 use of evidence-based management collaboratives to stimulate further uptake, 153–155 Transportation, in the hospital environment, 259 Transportation industry work hour regulation, 403–415, 421–424 aerospace industry, 413–415 aviation industry, 410–413 long-haul truck drivers, 408–410 marine employees, 405–408 railroad employees, 403–405 Triangular patient care units, 250–251 Truck drivers, long-haul, work hour regulation in, 408–410 Trust creating and sustaining, 115–118, 137–139, 149, 214, 292 in hospital administration, widespread loss among nursing staff, 4 presence of in magnet hospitals, 149 weakened, 137–139

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Turnover data, collecting valid and reliable from hospitals and nursing homes, 11, 200–201 Types of work units in which hospital-employed RNs spend more than half of their direct patient care time, 78, 173 U UAPs. See Unlicensed assistive personnel Uncertainty of knowledge base in health care, implications for patient safety defenses, 63 Union of Concerned Scientists, 402 Unit dose dispensing, 241 “Universal rooms,” 263 University HealthSystem Consortium, 207 University of California system, 389 University of Michigan Medical Center, 389 University of Pennsylvania Hospital, 389, 416 University of Pittsburgh, Center for Health Services Research, 151 Unlicensed assistive personnel (UAPs), 31n Unreliable workload estimates, for various patient classification levels, 185–186 Unsafe work and workspace design, 6–7 Unsafe workforce deployment, 5 Urinary tract infection (UTI), hospital-caused, 25, 168–169, 362 U.S. Air Force, 385 U.S. Air Mail Service, 410 U.S. Census Bureau, 74 U.S. Centers for Disease Control and Prevention (CDC), 151, 243 National Institute for Occupational Safety and Health, 215, 234, 262 National Nosocomial Infections Surveillance System, 75 U.S. Coast Guard, 405–408 U.S. Department of Commerce, Aeronautics Branch, 411 U.S. Department of Health and Human Services (DHHS), 46, 182–183 Agency for Healthcare Research and Quality, 2–3, 23 Centers for Medicare and Medicaid Services, 167, 170, 194, 197–199, 245 recommendations for, 9–11 U.S. Department of Labor, 71, 73 U.S. Department of Transportation, 403 U.S. Food and Drug Administration (FDA), 46, 241 U.S. General Accounting Office (GAO), 74, 88 “Using Innovative Technology to Enhance Patient Care Delivery” (conference), 209 UTI. See Urinary tract infection V VA. See Veterans Administration health system “Value-added” nursing activities, 257 Variation in staffing levels, 171–180 acute care hospital staffing, 171–178 nursing home staffing, 178–180 Variations in education and in experience and expertise among members of the nursing workforce, 66–70 Variations in nurse-to-patient ratios, 173 Variations in patient volume and/or acuity, accommodation of unpredicted, providing for “on-time” staffing or demand elasticity, 190–193 Variety of health care settings for nursing staff, 76–86 home care and community-based organizations, 84–85 hospitals, 76–82 nursing homes, 82–84 public health agencies, 85–86 Veterans Administration (VA) health system, 241, 300 Expert Advisory Panel on Patient Safety System Design, 294 geriatric evaluation and management interdisciplinary teams, 355 Patient Safety Improvement Initiative, 292 VHA Inc., 120, 133–135 Vigilance function, 35, 360 all employees empowered and engaged in ongoing, 288–291 communication, 289–290 constrained improvisation, 290 nonhierarchical decision making, 290 rewards and incentives, 291 training, 290–291

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Visual controls, 258 Vulnerability of the consumers of the “production process” in health care, implications for patient safety defenses, 62 W Waiting unnecessarily, in the hospital environment, 259 Waste categories in the hospital environment, 259 defects/quality control, 259 excess inventory, 259 excess motion, 259 poor utilization of resources, 259 process inefficiency, 259 transportation, 259 unnecessary waiting, 259 Wellspring Innovative Solutions, Inc., as a model of evidence-based management in nurses’ work environments, 152–153, 359–360 Women, predominating in nursing, 70–71 Work, in the Toyota Production System, 126 Work and workspace design to prevent and mitigate errors, 12–13, 226–285 addressing handwashing and medication administration first among work design initiatives, 13, 276 design of work hours, 227–238 design of work processes and workspace, 239–277 identifying strategies for safely reducing the burden of patient and work-related documentation, 13, 277 providing nursing leadership with resources to design the nursing work environment and care processes to reduce errors, 13, 276 reducing error-producing fatigue by prohibiting nursing staff from exceeding set shift limits, 12–13, 237 Work design and involving workers in work flow decision making, 121–124 paying ongoing attention to, 266–267 that promotes safety, 17, 315 Work design principles, 258–260 containing the effects of errors, 260 detecting errors early, 260 eliminating errors, 259 reducing error occurrence, 259 Work design process, 255–256 characteristics of individual performing the work, 255 characteristics of the organization, 256 characteristics of the physical environment, 256 tasks being performed, 255 tools and technologies being used, 255 Work environment aspects critical to patient safety that were not addressed in either prior report, 18, 55 threats posed by, 46–47 Work hour limitations in safety-sensitive industries, 227n, 384–435 effects of fatigue, 384–388 fatigue countermeasures programs, 415–417 health care professionals, 418 non-health care public service industries, 419–421 other public service providers, 396–403 transportation industry, 403–415, 421–424 work schedules of selected health care providers, 388–396 Work hours design of, 227–238 long, 43–44 research needed on the effects of successive days of sustained, 324 Work procedures and equipment, simplifying and standardizing, 260–261 Work processes need for safer, 323 threatening patient safety, 19, 48, 60 Work production components of all organizations, and corresponding patient safety defenses, 60 Work redesign, 245–246 getting started in, 269, 276–277 Work-related documentation, identifying strategies for safely reducing the burden of, 13, 277 Work sampling, 256–257 Work systems, high-involvement, 122 Work team effectiveness, theories of, 342–352

OCR for page 437
Keeping Patients Safe: Transforming the Work Environment of Nurses Worker involvement in actively managing the process of change, 121 throughout the design process, 260 Worker training, insufficient, 140–141 Workers connecting, in the Toyota Production System, 126 Workers involved in decision making, in magnet hospitals, 149–150 Workforce capability, 9–12, 162–225 collecting valid and reliable staffing and turnover data from hospitals and nursing homes, 11, 200–201 employing nurse staffing practices that identify needed nurse staffing for each patient care unit per shift, 10, 194 fostering interdisciplinary collaboration, 212–218 performing ongoing evaluation of effectiveness of nurse staffing practices with respect to patient safety, 10–11, 194 promoting safe staffing levels, 163–201 supporting interdisciplinary collaboration by adopting specific mechanisms and training in collaboration, 12, 217 supporting knowledge and skill acquisition and clinical decision making, 201–212 supporting nursing staff in their ongoing acquisition and maintenance of knowledge and skills, 11–12, 211–212 updating existing minimum standards for registered and licensed nurse staffing in nursing homes, 9–10, 182–183 Workforce deployment, threatening patient safety, 19, 48, 60 Working conditions, that discourage nursing staff from remaining in the workforce, 87–89 Workload changes, 80–82 Workload estimates, for various patient classification levels, inaccurate and unreliable, 185–186 Workspace design elements for general patient care rooms based on LEAN principles, 270–275 Workspace design for safety and efficiency, 248–255, 267–269, 276–277, 323 design of patient care units, 248–250 getting started in work redesign, 269, 276–277 Methodist Hospital, Clarian Health Partners, 267–269 patient transfers, 251–253 poor communication technology, 253–254 potential workspace design elements for safety, 269 sensory interference, 254–255 Y Youngest Science, The: Notes of a Medicine Watcher, 37 Z Zion, Libby, 393, 416