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From page 437... ... , 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, 164-166 437 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. Read the entire page →
From page 438... ... , 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, 300303 nursing cultures fostering unrealistic expectations of clinical perfection, 299-300 Barriers to effective team development and performance, 366-368 BCMA. Read the entire page →
From page 439... ... 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 Read the entire page →
From page 440... ... 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-healthrelated 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 INDEX 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 , . Read the entire page →
From page 441... ... , 365366, 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, 288291 441 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 . Read the entire page →
From page 442... ... 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 INDEX 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. Read the entire page →
From page 443... ... . paying ongoing attention to wor design, 266-267 reducing and compensating for handoffs, 263-264 remaining alert to the limitations of and risks created by technology, 266-267 root-cause analysis, 257 443 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 nursingrelated, 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. Read the entire page →
From page 444... ... , 257 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, 6,227232,384-435 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. Read the entire page →
From page 445... ... 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, 388396 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 ,, . Read the entire page →
From page 446... ... . .n-servlce 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, 240241, 303 Institute of Medicine (IOM) Read the entire page →
From page 447... ... mec :nan~sms ant training In collaboration, 12, 217 teams and performance outcomes, 342366 Tnterdi.scinlinarv 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, 184196 methods for predicting patient volume failing to keep pace with changes in hospital admission practices, 187188 problems in applying widely used tools to predict hospital staffing, 184-187 International Atomic Energy Agency, 76, 206, 295 447 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) Read the entire page →
From page 448... ... 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, 124131 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 Read the entire page →
From page 449... ... See Medical Expenditure Panel Survey Message logs, 266 Methodist Hospital, Clarian Health Partners, 267-269 449 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, 182183 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. Read the entire page →
From page 450... ... 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 INDEX 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 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. Read the entire page →
From page 451... ... . P :lyslclans Nurses' role in patient safety, 31-37 coordination and integration of care and services from multiple providers, 3637 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 nr~ctice.s nece.~.~nrv for .~nfetv .3�4 45 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 . Read the entire page →
From page 452... ... . ngomg ln-servlce 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, 369370 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 INDEX Organizational goals, safety performance 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 errorreporting 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. Read the entire page →
From page 453... ... imp. lcatlons tor 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, 252253 indirect hospital costs, 252 labor cost, 252 time elapsed, 252 frequent turnover of, 42 impact of patient transfers on length of stay, 252-253 monitoring, 32 . Read the entire page →
From page 454... ... , 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. Read the entire page →
From page 455... ... . 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 Read the entire page →
From page 456... ... , 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 INDEX 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-healthrelated 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, 1920, 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 Read the entire page →
From page 457... ... 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, 169-171 457 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! Read the entire page →
From page 458... ... , 365 Standardizing common work procedures and equipment, 258, 260-261 Standards and standards compliance requirements, streamlining, 247-248 Stapl7ylococcus aureus, outbreaks of linked to overtime, 390-391 INDEX 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 ,~ . Read the entire page →
From page 459... ... . management practices in nurses work environments, 131-147 use of evidence-based management collaboratives to stimulate further uptake, 153-155 1 ransportation, 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 in actively managing the process of loss among nursing staff, 4 change, 119-120 presence ofin magnet hospitals, 149 in building and nurturing collaboration, weakened, 137-139 217 Read the entire page →
From page 460... ... 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 Read the entire page →
From page 461... ... INDEX 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, 152153, 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 workrelated 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 Work design exceeding set shift limits, 12-13, 237 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, 260 461 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, 415417 health care professionals, 418 non-health care public service industries, 419-421 other public service providers, 396-403 transportation industry, 403-415, 421424 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, 260261 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, 342352 Read the entire page →
From page 462... ... . updating existing minimum standards for registered and licensed nurse staffing in nursing homes, 9-10, 182-183 INDEX 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, 253254 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 Read the entire page →

From page 437...

... , 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, 164-166 437 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.

Index Pages 437-462

Index
Pages 437-462