Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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Executive Summary
Executive Summary
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, individual health care practitioners, and experts on safety from a variety of disciplines. Key stimuli for this increased attention have included actions undertaken by the federal government to fund more research on why such errors occur and how to prevent them, to collect data on patient safety, to support new information technology for health care delivery, and to disseminate patient safety information to consumers and providers (Clancy and Scully, 2003)
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THE CRITICAL ROLE OF NURSES IN PATIENT SAFETY The 2.8 million licensed nurses and 2.3 million nursing assistants providing patient care in this country represent approximately 54 percent of all health care workers and provide patient care in virtually all locations in which health care is delivered -- hospitals; nursing homes; ambulatory care settings, such as clinics or physicians' offices; private homes; schools; and employee workplaces. When people are hospitalized, in a nursing home, having a baby, or learning to manage a chronic condition in their own home -- at some of their most vulnerable moments -- nurses are the health care providers they are most likely to encounter; spend the greatest amount of time with; and, along with other health care providers, depend on for their recovery.
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. In reviewing evidence on acute hospital nurse staffing published from 1990 to 2001, the AHRQ report Making Health Care Safer: A Critical Analysis of Patient Safety Practices (Seago, 2001:430)
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. These changes -- along with losses of chief nursing officers without replacement; decreases in the numbers of nurse managers; and increased responsibilities of remaining nurse managers for more than one patient care unit, as well as for supervising personnel other than nursing staff (e.g., housekeepers, transportation staff, dietary aides)
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Currently available methods for achieving safer staffing levels in hospitals, such as authorizing nursing staff to halt admissions to their unit when staffing is inadequate for safe patient care, are not employed uniformly by hospitals or nursing homes. Federal regulations governing nursing home staffing are over a decade old and do not reflect new knowledge on safe staffing levels.
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. A similar 6-month study of all adverse drug events in two tertiary care hospitals found that 38 percent occurred during the administration of the drug by nursing staff (Pepper, 1995)
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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. NEED FOR BUNDLES OF MUTUALLY REINFORCING PATIENT SAFETY DEFENSES IN NURSES' WORK ENVIRONMENTS No single action can, by itself, keep patients safe from health care errors.
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• Facilitate input of direct-care nursing staff into operational deci sion making and the design of work processes and work flow. • Be provided with organizational resources to support the acqui sition, management, and dissemination to nursing staff of the knowledge needed to support their clinical decision making and actions.
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Maximizing Workforce Capability Monitoring patient health status, performing therapeutic treatments, and integrating patient care to avoid health care gaps are nursing functions that directly affect patient safety. Accomplishing these activities requires an adequate number of nursing staff with the clinical knowledge and skills needed to carry out these interventions and the ability to effectively communicate findings and coordinate care with the interventions of other members of the patient's health care team.
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• Specify staffing levels that increase as the number of patients increase, and that are based on the findings and recommenda tions of the DHHS report to Congress, Appropriateness of Mini mum Nurse Staffing Ratios in Nursing Homes -- Phase II Final Report. • Address staffing levels for nurse assistants, who provide the ma jority of patient care.
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• Federal and state nursing home report cards should include stan dardized, case-mix–adjusted information on the average hours per patient day of RN, licensed, and nurse assistant care pro vided to residents and a comparison with federal and state stan dards. • During the next 3 years, public and private sponsors of the new hospital report card to be located on the federal government website should undertake an initiative -- in collaboration with experts in acute hospital care, nurse staffing, and consumer in formation -- to develop, test, and implement measures of hospi tal nurse staffing levels for the public.
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Finally, in response to evidence on inconsistent interprofessional collaboration among nursing staff and other health care providers, the committee makes the following recommendation: Recommendation 5-6. HCOs should take action to support in terdisciplinary collaboration by adopting such interdisciplinary practice mechanisms as interdisciplinary rounds, and by providing ongoing formal education and training in interdisciplinary collabo ration for all health care providers on a regularly scheduled, con tinuous basis (e.g., monthly, quarterly, or semiannually)
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• Schools of nursing, state boards of nursing, and HCOs should educate nurses about the threats to patient safety caused by fa tigue. Enabling nursing staff to collaborate with other health care personnel in identifying high-risk and inefficient work processes and workspaces and (re)
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As a result, all nursing staff are more inclined to be vigilant for errors and near misses, with a view toward learning from each event and strengthening the culture of safety accordingly. Action also is needed from state boards of nursing and Congress to enable strong and effective cultures of safety to exist.
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Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that are collected and analyzed by HCOs for internal use or shared with others solely for purposes of improving safety and quality. Summary Implementing all of the above recommendations will create the necessary bundles of mutually reinforcing patient safeguards in the work environments of nurses listed in Box ES-1.
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• Establish the organization as a "learning organization." Effective Nursing Leadership • Participates in executive decision making. • Represents nursing staff to management.
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Mechanisms That Promote Interdisciplinary Collaboration • Use interdisciplinary practice mechanisms, such as interdisciplinary patient care rounds. • Provide formal education and training in interdisciplinary collaboration for all health care providers.
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Defenses against human errors can be developed and put in place only if nursing staff are not afraid of reporting those errors and are involved in designing even stronger defenses. Finally, instituting all of these defense strategies can be accomplished only by individuals who have a vision of and command resources for the organization as a whole -- an organization's leadership and management.
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Accordingly, the committee makes the following recommendation: Recommendation 8-1. Federal agencies and private foundations should support research in the following areas to provide HCOs with the additional information they need to continue to strengthen nurse work environments for patient safety: • Studies and development of methods to better describe, both qualitatively and quantitatively, the work nurses perform in dif ferent care settings.
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2003 Survey of Hours Report: Direct and Total Hours per Patient Day (HPPD) by Patient Care Units.
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2002. Report to Congress: Appropriate ness of Minimum Nurse Staffing Ratios in Nursing Homes -- Phase II Final Report: U.S.
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3. Chicago, IL: National Council of State Boards of Nursing, Inc.
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