• It addresses aspects of the work environment that are critical to patient safety but are not addressed in either of the two prior reports, such as the adequacy of staffing levels and worker fatigue.

  • It unifies the prior two IOM reports and this report into a framework that all HCOs can use to construct work environments more conducive to patient safety. This framework integrates the multiple, mutually reinforcing strategies that are needed within various components of the work environment to keep patients safe from the ever-present latent conditions and human errors that pose risks to patient safety (as described in Chapter 1).

THE NEED FOR BUNDLES OF MULTIPLE, MUTUALLY REINFORCING PATIENT SAFETY DEFENSES

Research from a variety of disciplines clearly documents that errors and adverse events, especially those that are difficult to correct, often result from multiple, interdependent factors that converge to impair the performance of organizations (Goodman, 2001; Perrow, 1984; Ramanuajm, forthcoming). Errors and accidents often originate within multiple steps in work design and implementation—in fact, in all steps of a production process—and in several components simultaneously. Consequently, reducing error and increasing patient safety are not likely to be achieved by any single action; rather, a comprehensive approach, addressing all components of health care delivery within an organization, is required.

Evidence in support of this contention comes from health services and nursing research; behavioral and organizational research on work and workforce effectiveness; human factors analysis and engineering; studies of organizational disasters and their evolution; and studies of high-reliability organizations.1 For example, intensive study of individual disasters has yielded valuable information about the circumstances leading up to each catastrophic error. The combined knowledge obtained from multiple case studies yields a body of principles that, when applied, can reasonably be expected to reduce the occurrence of errors, their adverse consequences, or both (Reason, 1990). This approach is employed in the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) analyses of the root causes of sentinel events.

Similarly, organizational research conducted by social scientists has provided a multilevel view of organizations by focusing on the complex levels of human organizing, including individuals, dyads, groups, networks, firms,

1  

As noted in Chapter 1, high-reliability organizations are defined as high-risk industries (e.g., nuclear power production) with low accident rates.



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