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Keeping Patients Safe: Transforming the Work Environment of Nurses
federally required OASIS assessment instrument for each Medicare beneficiary receiving Medicare home health care services, while nursing home nurses must complete a similar federally prescribed MDS for nursing home residents. These data sets are not always maximally compatible with internal documentation systems used by HCOs (e.g., the OMAHA system for home health care) and can create redundancies. Finally, nurses sometimes practice lengthy narrative charting as a defense against increasing litigation.
To the extent that paperwork and other documentation requirements lessen the time nurses have for direct contact with patients, they contribute to the reduced availability of nurses that has been shown to affect patient safety. Estimates from work sampling studies and surveys of nurses within individual hospitals of the amount of time spent in patient care documentation range from 13 to 28 percent (Korst et al., 2003; Pabst et al., 1996; Smeltzer et al., 1996; Upenieks, 1998; Urden and Roode, 1997). Home care nurses are estimated to spend a much greater proportion of their time in documenting care. According to some estimates, home health nurses spend approximately twice as much time in documenting patient care as do hospital nurses, in part because of more prescriptive federal regulatory requirements (Trossman, 2001). Completion of required paperwork is also cited as one reason nurses work overtime; because it cannot be accomplished in an 8-hour shift, it becomes a form of unpaid mandatory overtime (Trossman, 2001).
THREATS TO PATIENT SAFETY POSED BY WORK ENVIRONMENT FACTORS
All of the changes affecting the work environment of nurses described above can constitute latent factors conducive to health care errors. This fact is dramatically expressed in the text, but not the title, of a widely cited Chicago Tribune article, “Nursing Mistakes Kill, Injure Thousands Annually” (Berens, 2000). This article reports the results of an analysis of records from the U.S. Food and Drug Administration and other Department of Health and Humans Services agencies, federal and state files of annual hospital surveys and complaint investigations, court and private health care files, and nurse disciplinary records for every state. The analysis detected 1,720 deaths and 9,584 injuries among hospital patients resulting from the actions or inactions of RNs over a 5-year period, and 119 deaths and 564 patient injuries due to errors on the part of unlicensed NAs. Because of incomplete reporting, the article notes that these numbers should be interpreted as underestimates. Despite its title, the article does not point to willful wrongdoing or carelessness on the part of the RNs and NAs associated with these errors. Instead, it calls attention to their working conditions as the underlying causes (latent conditions) of the errors, prominently citing