and distractions associated with nursing tasks; workspaces not designed to facilitate nursing organization and activities; limited access to information systems; and other common work practices, including using nurses to perform such non-nursing duties as picking up blood products and delivering laboratory specimens.

Punitive Cultures That Hinder the Reporting and Prevention of Errors

To Err Is Human also calls attention to the need to create organizational cultures of safety that promote the reporting, analysis, and prevention of errors within all HCOs. The committee finds that while some progress has been made in fostering such cultures, full implementation has not yet been achieved. Incidents have been reported in which nurses who were involved in the commission of an error but found blameless by a number of independent authoritative bodies were unjustly disciplined by state regulatory agencies. HCOs need the assistance of state and federal oversight organizations if they are to create fully effective programs for detecting and preventing patient care errors in their organizations.


No single action can, by itself, keep patients safe from health care errors. Because multiple components and processes of HCOs create situations that nurture errors in the work environments of nurses, multiple, mutually reinforcing changes in those environments are needed to substantially reduce errors and increase patient safety. To this end, defenses must be created in all organizational components: (1) leadership and management, (2) the workforce, (3) work processes, and (4) organizational culture. Bundles of changes are needed within each of these components to strengthen patient safety.

Transformational Leadership and Evidence-Based Management

Creating work environments for nurses that are most conducive to patient safety will require fundamental changes throughout many HCOs in terms of how work is designed, how personnel are deployed, and how the very culture of the organization understands and acts on the science of safety. These changes require leadership capable of transforming not just physical environments, but also the beliefs and practices of both nurses and other health care workers providing patient care and those in the HCO who establish the policies and practices that shape those environments—the individuals who constitute the management of the organization.

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