C-1

 

A Comparison of Work Hour Limitations in Selected Safety-Sensitive Industries,

 

418

FIGURES

ES-1

 

Sources of threats to patient safety in the work environment and corresponding safety defenses,

 

19

2-1

 

The basic elements of production,

 

58

2-2

 

Human contributions to error within each production component,

 

59

2-3

 

Basic work production components of all organizations and corresponding patient safety defenses,

 

60

5-1

 

Total nurse staffing hours per resident in all U.S. nursing facilities, 1993–2001,

 

179

6-1

 

Scheduled and actual shift durations,

 

235

7-1

 

A Decision Tree for determining the culpability of unsafe acts,

 

304

BOXES

ES-1

 

Necessary Patient Safeguards in the Work Environment of Nurses,

 

16

1-1

 

Patient Monitoring in an Intensive Care Unit: An Example,

 

33

3-1

 

The Benefits of RN Surveillance: A Case Example,

 

92

3-2

 

Time Required for Emotional Support: A Case Example,

 

98

4-1

 

The Toyota Production System,

 

126

7-1

 

Litigation and Regulatory Barriers to Effective Safety Cultures: Two Case Examples,

 

302

8-1

 

Necessary Patient Safeguards in the Work Environment of Nurses,

 

314



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