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
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
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
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
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
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
increased patient satisfaction, 319
potential financial advantages, 319–322
Benefits of RN surveillance, 92–93
Blame
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
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
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
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
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
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
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
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
line management in, 57
model for safety defenses in work environments, 56–61
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
FMEA. See Failure modes and effects analysis
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
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
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 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
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
preceptorships and residencies for new nurses, 207–208
simulation techniques, 208–209, 346, 372
strategies to support nursing staff in ongoing acquisition of, 207–212
Knowledge and technology, rapid increases in new, 44–45
Knowledge base uncertainty in health care, implications for patient safety defenses, 63
Knowledge culture within the organization, assessing the existing, 129–130
Knowledge management
aligning incentives to reinforce and facilitate uptake of, 131
limited, 144–146
in magnet hospitals, 150
L
Labor cost, of patient transfers, 252
Labor organizations, recommendations for, 13–14
Lapses, 261n
Latent conditions, 29
Law experts, recommendations for, 13
Leadership
commitment to safety, 287–288
and evidence-based management structures and processes, 16, 314
in magnet hospitals, 148–149
modeling of collaborative behaviors, 216
threatening patient safety, 19, 48, 60
transformational, 110–111
“LEAN” operations, 256–258, 269–275
point-of-use storage, 258
standardizing work, 258
streamlined physical plant layout, 258
visual controls, 258
“Learned helplessness,” 31
“Learning organizations,” 290, 292
Learning process
actively managing, 125–128
providing time for, 130–131
taking advantage of all sources of knowledge, 125
transferring knowledge quickly and efficiently throughout the organization, 125–128
using systematic experimentation to generate new knowledge internally, 125
Legible data, 265
specifying staffing levels for, 182
Licensed practical nurses (LPNs), 31n, 32, 66
education for, 67
Licensed vocational nurses (LVNs), 31n, 66
education for, 67
Lindbergh, Charles, 410
Line management, role in safety defenses in work environments, 57
Line operations safety audit (LOSA), 374–375
Litigated barriers, to effective safety cultures, 300–303
LOSA. See Line operations safety audit
LPNs. See Licensed practical nurses
LVNs. See Licensed vocational nurses
M
Magnet hospitals, 147–150, 207
involving workers in decision making, 149–150
knowledge management, 150
leadership, 148–149
as models of evidence-based management in nurses’ work environments, 147–150, 207
presence of trust, 149
Making Health Care Safer: A Critical Analysis of Patient Safety Practices, 3, 182, 187, 210, 232
Management practices, 112–131
actively managing the process of change, 118–121
balancing the tension between efficiency and reliability, 114–115
creating a learning organization, 124–131
creating and sustaining trust, 115–118, 137–139, 149, 214, 292
involving workers in work design and work flow decision making, 121–124
threatening patient safety, 19, 48, 60
Management Practices and Processes Questionnaire, 362
Managerial leadership, recommendations for, 8, 14
Managing the Risks of Organizational Accidents, 29n, 301
Mandatory overtime hours, 234, 237
Marine employees, work hour regulation in, 405–408
Marketplace-driven responses to evidence on staffing and patient safety, 196–201
need for more accurate and reliable staffing data, 198–201
report cards on performance, 196–198
MDS. See Minimum data set
Measurement
in actively managing the process of change, 120
lack of, 141
of patient acuity, standardizing approach to, 323
of safe care delivery practices, of work teams and collaborative groups, 373–375
Medicaid Cost Reports, 199
Medicaid On-line Survey and Certification Report (OSCAR), 169
Medical Expenditure Panel Survey (MEPS), Nursing Home Component, 83
Medical-surgical units
acute care hospital staffing levels in, 172, 176–178
changes in workload in, 81
Medicare
home health care requirements of, 34–35
Medicare Act, 395
Medicare Payment Advisory Commission, 301
Medication administration, 239–242
addressing first among work design initiatives, 13, 276
causes of errors in, 239–240
potential remedies for errors in, 240–242
See also Adverse drug events
Meenan, John, 412
MEPS. See Medical Expenditure Panel Survey
Message logs, 266
Methodist Hospital, Clarian Health Partners, 267–269
Military personnel, work hour regulation for, 397–400
Minimum data set (MDS), 34, 46, 168, 245
Minimum standards for registered and licensed nurse staffing in nursing homes, updating existing, 9–10, 182–183
Missions Operations Directorates, 413
Monitoring patient status, 32
by direct-care nursing staff, 91–94
Motion, excess, in the hospital environment, 259
Motor Carrier Act of 1935, 408
Multiple providers, coordination and integration of care and services from, 36–37
Multiple purposes, incentives for “gaming” the system created by, 186–187
Mutual trust and respect, a necessary precursor to collaboration, 214
N
NACNEP. See National Advisory Council on Nurse Education and Practice
NAs. See Nursing assistants
NASA. See National Aeronautics and Space Administration
National Advisory Council on Nurse Education and Practice (NACNEP), 203
National Aeronautics and Space Administration (NASA), 414
Ames Fatigue Countermeasures Group, 415
Aviation Human Factors Team, 412
Aviation Safety Reporting System, 412
National Association for Home Care, 85
National Commission on Sleep Disorders Research, 396
National Council of State Boards of Nursing, 90n, 204, 234
recommendations for, 15
National Institute for Occupational Safety and Health (NIOSH), 215, 234, 262
National Institutes of Health, 302
National Joint Practice Commission, 213
National Nosocomial Infections Surveillance System, 75
National Opinion Research Center, General Social Survey, 88
National Patient Safety Advisory Board, at Kaiser Permanente, 307
National Sample Survey of Registered Nurses (NSSRN), 67, 70, 79n, 88, 200, 234
National Science Foundation (NSF), Industry/University Collaborative Research Centers, 155
National Transportation Safety Board (NTSB), 230, 386
Nationwide nursing shortage, 86–87
Near misses, reporting as well as errors, 293–294
New Jersey State Assembly, 395
New York Hospital Association, 394
New York State Department of Health, 394
Ad Hoc Advisory Committee on Emergency Services, 394
NIC. See Nursing Intervention Classification system
Night shift workers, 228–229, 386
strategies to help compensate for fatigue, 324
Nightingale, Florence, 132
Nightingale style patient care units, 250
NIOSH. See National Institute for Occupational Safety and Health
Noise reduction, 254
Non-health care public service industries
application of training standards from, 378
work hour limitations in, 419–421
Non-health-related strategies, effect in achieving collaboration and error reduction, 325
Nonhierarchical decision making, in ongoing vigilance, 290
Nonpunitive approach, to error reporting, 292
NRC. See Nuclear Regulatory Commission
NSF. See National Science Foundation
NSSRN. See National Sample Survey of Registered Nurses
NTSB. See National Transportation Safety Board
Nuclear power plant workers, work hour regulation for, 400–403
Nuclear Regulatory Commission (NRC), 400, 402
Nuffield form patient care units, 250
Numbers of nurses essential to patient safety, 163–169
in acute care hospitals, 164–166
in nursing homes, 166–169
Nurse expertise, committing resources to build, 216
Nurse leaders
acquiring for all levels of management, 8, 136
recommendations for, 8
Nurse staffing, 233–236
employing practices that identify needed nurse staffing for each patient care unit per shift, 10, 194
estimates derived from staffing studies, 175
hours per resident in all U.S. nursing facilities, 179
impact of leaner levels of, 3, 5
work hours of hospital nurses, 234–235
work hours of nursing staff in nursing homes, 235–236
Nurse-to-patient ratios, 164n, 172
in ICUs, 172
in medical-surgical units, 172
ranges of, 172
in step-down units, 172
Nurse training
financial pressures to curtail, 5
providing for the newly-licensed, 5
Nurse work processes, reduced patient safety due to inefficient, 243–248
Nurses
discouraged by working conditions from remaining in the workforce, 87–89
diversity among, 72–73
experiencing “positive relationships” with physicians, 215–216
inconsistent collaboration with other health care providers, 215–216
“inevitable availability” of, 36
as the largest component of the health care workforce, 31–32
nationwide shortage of, 86–87
preceptorships and residencies for new, 207–208
reasons for documentation by, 46
using from external agencies, 193
work schedules of, 388–391
See also Recruitment and retention of nursing staff across clinical settings;
Relationships between nurses and physicians
Nurses’ role in patient safety, 31–37
coordination and integration of care and services from multiple providers, 36–37
nurses as the largest component of the health care workforce, 31–32
surveillance and “rescue” of patients, 32, 34–36
Nurses’ time
consumed by documentation of patient information, 6
consumed by PCSs, 187
documentation and paperwork, 45–46
elapsed during patient transfers, 252
increased demands on, 45–46
and interruptions, 45
required for emotional support, 98–99
spent documenting patient care activities, 244–245
Nurses’ work, information needed on, 322
Nurses’ work environments
frequent failure to follow management practices necessary for safety, 3–4
punitive cultures that hinder the reporting and prevention of errors, 7
a threat to patient safety, 3–7
transforming, 47–52
unsafe work and workspace design, 6–7
unsafe workforce deployment, 5
Nursing
inseparably linked to patient safety, 3–7, 23–52
potential loss of a common voice for, 133–135
team, 80
Nursing actions
defending patients against errors, 3
relation to patient outcomes, 2
“value-added,” 257
Nursing assistants (NAs), 31n, 32, 66
deaths and injuries caused by, 46
education for, 67–68
employment settings of, 77
need for ongoing training of, 205
Nursing cultures, fostering unrealistic expectations of clinical perfection, 299–300
Nursing experts, recommendations for, 13
Nursing Home Component, 83
Nursing Home Reform Act, 83
Nursing homes
current regulations governing, 5
numbers of nurses essential to patient safety in, 166–169
nursing staff in, 82–84
recommendations for, 10–11, 194
report cards needed, 196–197
staffing data needed, 198–200
staffing levels in, 178–180
updating existing minimum standards for registered and licensed nurse staffing in, 9–10, 182–183
work hours of nursing staff in, 235–236
Nursing Intervention Classification (NIC) system, 90n, 96
Nursing leadership
concerns about changes in, 132–136
providing with resources to design the nursing work environment and care processes to reduce errors, 13, 276
Nursing staff acquiring knowledge and skills
decision support at the point of care delivery, 209–212
individualized training, 208
ongoing strategies to support, 207–212
preceptorships and residencies for new nurses, 207–208
simulation techniques, 208–209, 346, 372
Nursing Staff in Hospitals and Nursing Homes: Is It Adequate, 167
Nursing stations, 249
Nursing units, safe staffing levels at the level of different, 323–324
Nursing workforce, 65–107
problems with recruitment and retention of nursing staff across clinical settings, 86–89
unique demographic characteristics of the nursing workforce, 70–76
variations in education and in experience and expertise among members of the nursing workforce, 66–70
variety of ways in which direct-care nursing staff provide patient care, 90–101
what nurses do, 89–101
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
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
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
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
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
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
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
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
Sleep debt, 231
Sleep deprivation, effect on clinical performance, 392–393
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
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
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
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
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
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
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
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
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