Skip to main content

Currently Skimming:

6 Work and Workspace Design to Prevent and Mitigate Errors
Pages 226-285

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 226...
... The long work hours of some nurses also cause fatigue and contribute to their making errors. Inefficient care processes and workspace design, while not intrinsically dangerous to patients, decrease patient safety to the extent that they reduce the time nurses have for monitoring patients and providing therapeutic care.
From page 227...
... This chapter reviews the evidence on the design of nurses' work hours, work processes, and workspaces, primarily as they relate to patient safety, but also with respect to efficiency (which, as noted above, is a contributory factor in safety)
From page 228...
... In nurses' work environments, fatigue is produced by shift work and extended work hours. Shift Work Since almost all physiological and behavioral functions are affected by circadian rhythms, the time of day when work must be completed is important.
From page 229...
... Extended Work Hours Shifts of 12 or more hours with limited opportunity for rest and no opportunity for sleep are referred to as "sustained operations" (Kruger, 19891. Workers engaged in sustained operations in a variety of occupations report greater fatigue at the end of their shifts than do those who work 8hour shifts (Milis et al., 1983; Rosa, 1995; Ugrovics and Wright, 19901.2 Studies in a variety of industries also show that accident rates increase during overtime hours (Kogi, 1991; Schuster, 19851; rates rise after 9 consecutive hours, double after 12 hours (Hanecke et al., 1998)
From page 230...
... Another time, again about 4 a.m., I would sometimes stop in the middle of the floor and forget what I was doing" (California Nurses Association, 20031. Fatigue is also exacerbated by working increased numbers of shifts without a day off (Dirks, 1993; Knauth, 1993)
From page 231...
... night shifts in seven wards of a Japanese university hospital, several compensatory measures were employed to protect against the dual effects of sustained operations and night shift work. These measures included increases in the numbers of night staff to allow all nursing staff to take a 2-hour nap in a dedicated resting room.
From page 232...
... Evidence on Nurse Work Hours and the Commission of Errors Researchers conducting the evidence review presented in the AHRQ report cited above (The et al., 2001) were unable to locate research that could help identify the specific numbers of hours worked by health care personnel, including nurses, beyond which patient safety is threatened.
From page 233...
... Nurses working on specialized units, such as the operating room, dialysis units, and some intensive care units, may be required to be on call in addition to their regularly scheduled shifts (Rogers, 20021. Representative, quantitative data describing the work hours of nurses are scarce.
From page 234...
... Work Hours of Hospital Nurses Data collected from the 2000 National Sample Survey of Registered Nurses indicate that full-time hospital nurses (including direct-care, administrative, and other hospital nurses) worked on average 42.2 hours per week, in contrast to their average scheduled hours of 39.3 hours per week (Spratley et al., 20001.
From page 235...
... . Work Hours of Nursing Staff in Nursing Homes Research on the work hours of nursing staff in nursing homes also has revealed extended work hours.
From page 236...
... The recent AHRQ-funded study of nurse work hours and health care errors discussed above provides additional compelling evidence of the effect of nurses working long hours on patient safety. The committee reviewed evidence on how other safety-sensitive industries nuclear energy production, public and commercial transportation, the military, police, and firefighters have responded to such evidence.
From page 237...
... Consequently, while the committee believes HCOs might want to limit their use of mandatory overtime in the interest of nurse retention and recruitment, excessive hours endanger patient safety regardless of whether they are worked under a mandate or on a voluntary basis. The committee consequently recommends that working more than 12 hours in any 24-hour period and more than 60 hours in any 7-day pe
From page 238...
... Similarly, in any instance where a nursing shortage prevents an HCO from securing sufficient nurses to prevent work hours in excess of 12 hours in any 24-hour period and more than 60 hours in any 7-day period, this information also should be disclosed to the public, so that elective admissions can be referred to other facilities or delayed until staffing is remedied. If an admission cannot be delayed or referred to another HCO, the patient and their family should be informed about the shortage of staffing and that nursing staff is working under conditions adverse to patient safety.
From page 239...
... Inherent Risks to Patient Safety in Some Nursing Work Processes Flaws in work or equipment design, equipment failures, and unanticipated interactions in work processes are recognized threats to safety in a many industries, including health care (Hymen, 1994; Senders, 19941. Medication administration and handwashing are two common nursing activities well documented as involving threats to patient safety.
From page 240...
... as important strategies for reducing medication errors at the point of medication administration by nurses: unit dose dispensing, bar-coding of medications, and use of "smart" infusion pumps.7 7Murray (2001) also examined automated medication dispensing systems drug storage or cabinet dispensing systems that allow nurses to obtain medications at the point of use (some at the bedside)
From page 241...
... Unit dose dispensing is common on general medical and surgical hospital units, but less so in intensive care units, operating rooms, and emergency departments. In the latter areas, bulk medication stock systems are still found.
From page 242...
... Effective redesign of medication administration also depends on the creation of a culture of safety and the establishment of a fair and just error-reporting system that is conducive to the discovery of medication errors (as discussed in Chapter 71. Han~lwashing Absence of handwashing is an example of a health care error of omission an error that results from the failure to take an action, as opposed to an error of commission accompanying the performance of an action.
From page 243...
... Some also have suggested that the application of behavior theory and human factors approaches to infection control practices might help achieve sustained increases in handwashing rates (Lautenbach, 2001~. Reduced Patient Safety Due to Inefficient Nurse Work Processes A number of studies provide evidence that nurses spend a significant portion of their time in activities that are inefficient and decrease the amount of time they have available to monitor patient status, provide therapeutic patient care, and educate patients.
From page 244...
... Documenting patient care and completing other paperwork to meet facility, insurance, private accreditation, state, and federal requirements, as well as to furnish information needed by other providers, is uniformly cited as imposing a heavy demand on nurses' time in hospitals, nursing homes, home health agencies, and community and public health settings. Estimates from work sampling studies and surveys of nurses within individual hospitals of the amount of time spent in patient care documentation range from 13 to 28 percent (Pabst et al., 1996; Smeltzer et al., 1996; Upenieks, 1998; Urden and Roode, 1997)
From page 245...
... . Other documentation pertains to nursing care and typically includes patient care plans; progress notes, flow charts, and shiftto-shift documentation or reports; medication administration and treatment records; patient education; admission, discharge, and transfer notes; justification for use of restraints; and patient classification systems (Butler and Bender, 1999; Smeltzer et al., 19961.
From page 246...
... In both settings, it is associated with reducing the amount of time nurses spend in documenting care (Blachly and Young, 1998; Stephens and Mason, 1999; Wroblewski and Werrbach, 1999~. Some of the most effective strategies for achieving more-efficient documentation result from multidisciplinary documentation redesign initiatives (Brunt et al., 1999; Mosher et al., 1996; Smeltzer et al., 1996~.
From page 247...
... Successful automation initiatives also are associated with the use of computerized patient records (Clayton et al., 2003; Walker and Prophet, 1997~. As noted earlier, however, internal efforts by HCOs alone are not likely to maximize documentation efficiency and utility because many documentation demands are imposed by external entities, including regulators and payors.
From page 248...
... Design of Patient Care Units The majority of hospital in-patient care is delivered on patient care units (also called "nursing units") , where patients are grouped according to age, diagnosis, or clinical condition (e.g., medical, surgical, pediatric, oncology, intensive care, or cardiology)
From page 249...
... · Nursing station The nursing station is the hub of the nursing unit for both simple and complex communications in a multitucle of care clelivery processes. Some refer to it as the "so-called" nursing station, noting that it has become the location for the unit secretary as well as all health professionals who spenci any time on the patient care unit, inclucling physicians, pharmacists, respiratory therapists, physical therapists, clieticians, social workers, and pastoral care staff (Hamilton, 19991.
From page 250...
... Some trauma or cardiovascular intensive care units are still configured as open wards for high-acuity surgical patients. Critical-care unit shapes (e.g., circular, linear, horseshoe, triangle)
From page 251...
... · The majority of the nurses' time was spent walking between the patient rooms and the nursing unit core, or in the nursing station. Patient Transfers The transfer or hand-off of patients from nurse to nurse, shift to shift, unit to unit, and HCO to HCO has also been identified as a potential source of errors and adverse patient events (Cook et al., 20001.
From page 252...
... The number of transfers increased even more with the creation of progressive, step-down, or transition units, which offer an intensity of nursing service between that of an intensive care and a general medical-surgical unit. Thus, it is not unusual to see a patient cared for by five different nursing units e.g., operating room, postanesthesia care unit, critical care unit, step-down unit, and general-medical surgical unit during his or her hospital stay.
From page 253...
... . A study of nursing units at two large metropolitan hospitals found that almost 70 percent of nurse calls did not require a licensed nurse
From page 254...
... While most studies of the effects of noise in the work environment have been conducted in non-health care settings, the contribution of noise levels to nurse stress and work distractions is increasingly being documented (Morrison et al., 2003; Topf, 20001. In health care facilities, sources of noise can range from overhead paging systems and equipment alarms to heating, ventilation, and air-conditioning (HVAC)
From page 255...
... i°This section incorporates content from a paper commissioned by the committee on "Reducing Workload and Increasing Patient Safety Through Work and Workspace Design," prepared by Pascale Carayon, Ph.D.; Carla Alvarado, Ph.D.; and Ann Schoofs Hundt, Ph.D. All are with the Center for Quality and Productivity Improvement, Department of Industrial Engineering, University of Wisconsin-Madison.
From page 256...
... For each observation, data are recorded on the task being performed (Carayon et al., 20031. Work sampling has been used to obtain insights into how nursing staff use their time, identify problem areas, and provide information for unit and work redesign (Linden and English, 1994; Pedersen, 1997; Scherube!
From page 257...
... Waid and Shojania (2001) note that root-cause analysis is a labor-intensive process, and that there is not yet evidence that by itself it can improve patient safety.
From page 258...
... Rather, they are complementary and can be used together (Alukal, 2003; Smith, 20031. Work design principles Regardless of the resources, approaches, and sources of expertise an HCO is able to bring to bear on a specific work design effort, principles for effective and safe work design have been identified that can guide all work (re)
From page 259...
... in the following subsections, aim to create reliable and safe patient care processes by: · Eliminating errors changing work processes so errors cannot be made. While the total elimination of all errors is impossible, work design principles should aim to continuously eliminate errors consistent with principles of continuous quality improvement, the defect-free goals of the Toyota Production System described in Chapter 4, six sigma DMAIC approaches to error reduction, and other improvement approaches that have "zero errors" as their goal.
From page 260...
... . Resources and work processes also differ on nursing units, as do patient levels of care and the experience level of nurses (Deutschendorf, 20031.
From page 261...
... When health professionals have been asked to report their perceptions of why medical errors occur, interruptions and distractions have frequently been cited (Ely et al., 19951. Nurses frequently cite distractions and interruptions as contributing to their commission of medication errors (Wakefield et al., 1998; Walters, 19921.
From page 262...
... , 75 percent of the 674 RN respondents who were currently employed as a full-time hospital or nursing home general-duty/staff nurse agreed or agreed strongly that "my job requires long periods of intense concentration"; 82 percent similarly agreed that "I work very fast"; and 79.6 percent agreed that "tasks are often interrupted without being completed. " i3 Studies of crew resource management in aviation provide insight into how to limit the effects of interruptions and distractions in that setting (Dismukes et al., 19981.
From page 263...
... "Universal rooms," singlestay units, and acuity-adaptable rooms all aim to place a single patient in a care room or nursing unit for his/her entire hospital stay (Gallant and Lanning, 20011. The room or unit adapts to the changing health status of the patient, eliminating the need for patient transfers.
From page 264...
... The increase in safety and efficiency achieved through automated patient records integrated with other clinical information systems is well illustrated by the automated information systems in place at Intermountain Health Care in Salt Lake City (Peck et al., 19971. Access to patient information is facilitated through automated patient records.
From page 265...
... Intermountain Health Care identifies other benefits of automated patient records integrated with automated clinical information systems. These benefits include the following: · Data that are organized and legible The nurse can see all of the prescribed drugs for a patient in one location; the doses are written clearly, and names are spelled correctly.
From page 266...
... Remaining alert to the limitations of and risks created by technology In searching for ways to improve patient safety, technology is often proposed as a strategy. Despite its potential, however, patient safety experts caution that technology by itself is not a panacea.
From page 267...
... Whenever a technology is implemented, then, the human factors characteristics of its design and its potential positive anal negative influences on other work system elements should be studied. Paying ongoing attention to work design Successful implementation of work redesign is not a one-time effort.
From page 268...
... support future care delivery while solving patient flow problems. To these ends, it would be necessary to shift indirect time back to the nurse and patient care by reducing the steps necessary for nursing staff to obtain supplies, reduce transfers of patients, rework the care delivery model, minimize delays in patient placement and waits in holding areas, eliminate equipment duplication, maximize technology for efficiency, and have patient and caregiver information readily available at the point of care.
From page 269...
... although there are special considerations for neonatal intensive care units (Graven, 19971. The committee notes that little research has been conducted establishing the efficiency and effectiveness of these measures in improving patient safety.
From page 270...
... Eliminate the need for many intra-unit patient transfers, reduce the workload index; conserve critical care beds; and improve the throughput and capacity of the hospital. Bed types Beds with built-in functionality (scales, fall Eliminate or reduce monitors, chair-bed status, motorized redundant devices (scales, drives)
From page 271...
... Through self/familycenterec care, nursing time can be preserved for .
From page 272...
... . , to permit patient transfers to the toilet without additional lifting or equipment, thus reducing .
From page 273...
... Support decentralized nursing stations for maximum efficiency. Eliminate nonvalue-added nursing time and motion.
From page 274...
... Improve patient safety (enhanced observation/fall reduction/reduced waits and delays)
From page 275...
... aThis does not apply to neonatal intensive care units, where exposure to direct sunlight has risks for the pre-term infant (Graven, 1997)
From page 276...
... HCOs should provide nursing leadership with resources that enable them to design the nursing work environment and care processes to reduce errors. These efforts must directly involve direct-care nurses throughout all phases of the work design and should concentrate on errors associated with: · Surveillance of patient health status.
From page 277...
... 2003. Enabling technologies promise to revitalize the role of nursing in an era of patient safety.
From page 278...
... Reducing Workload and Increasing Patient Safety through Work and Workspace Design. Paper commissioned by the Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety Case J
From page 279...
... 1997. Failure mode and effects analysis: An interdisciplinary way to analyze and reduce medication errors.
From page 280...
... Report commissioned by the IOM Committee on the Work Environment for Nurses and Patient Safety. Hendrich A, Nyhuis A, Kippenbrock T
From page 281...
... 2002. Using BCMA software to improve patient safety in Veterans Administration Medical Centers.
From page 282...
... eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
From page 283...
... Work Hour Regulation in Safety-Sensitive Industries. Paper commissioned by the Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety.
From page 284...
... 1999. Nurses' workload associated with 16-h night shifts.
From page 285...
... 2001. Reducing light and sound in the neonatal intensive care unit: An evaluation of patient safety, staff satisfaction and costs.


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.