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Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

step-down units, 172, 178

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Apollo 13, 414–415

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

of patients, 32, 34

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

of record systems, 246, 266

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

increased patient satisfaction, 319

potential financial advantages, 319–322

Benefits of RN surveillance, 92–93

Blame

assignment of, 27–28, 301–302

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

worker involvement, 121, 142

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Empowerment, 122–123, 363

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

discovering, 30, 63, 292

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

leadership and, 16, 314

line management in, 57

model for safety defenses in work environments, 56–61

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

“Float nurses,” 192, 212–213

FMEA. See Failure modes and effects analysis

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

magnet, 147–150, 207

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 Error, 29n, 57

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

Licensed nurses, 31n, 76n

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

payments by, 37–38, 84

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

MEDLINE database, 144, 357

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

longer work hours, 6, 43–44

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

“float,” 192, 212–213

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

effective, 16, 314

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

mandatory, 234, 237

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

adequate staffing, 16–17, 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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
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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

“Slack,” 191, 263

Sleep debt, 231

Sleep deprivation, effect on clinical performance, 392–393

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

high, 42–43, 319–320

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

work processes, 19, 48, 60

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

VHA Inc., 120, 133–135

Vigilance function, 35, 360

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

that promotes safety, 17, 315

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

Suggested Citation:"Index." Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: The National Academies Press. doi: 10.17226/10851.
×

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

Zion, Libby, 393, 416

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Keeping Patients Safe: Transforming the Work Environment of Nurses Get This Book
×

Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses’ working conditions and demands.

Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform – monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis – provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system.

During the past two decades, substantial changes have been made in the organization and delivery of health care – and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk.

This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.

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