gram has required that an RN perform a comprehensive, detailed assessment of each Medicare beneficiary receiving Medicare-covered home health care at the initiation of home health care services and at regular intervals thereafter.⁴ The nurse performing this assessment must assess the patient’s health status and health care and support needs, as well as items included in the Medicare Outcome and Assessment Information Set (OASIS) that address the patient’s history, and “sensory status, integumentary status, respiratory status, elimination status, neuro/emotional/behavioral status, activities of daily living, [and] medications,” among other information.⁵

While performing these assessments (and also when delivering therapeutic treatment and patient education), nurses are functioning at the “sharp end” of the health care system because of their immediate link to the patient. This ongoing vigilance function often thrusts nurses into a role that has been described as the “front line” of patient defense (JCAHO, 2001). Studies of organizations with a strong track record of high reliability and safety have shown that such vigilance by front-line workers is essential for detecting threats to safety before they actually become errors and adverse events (Roberts, 1990; Roberts and Bea, 2001). Because licensed nurses and NAs work at the “sharp end” of health care delivery, they are key instruments for carrying out such vigilance in health care.

The goal of this nursing surveillance or vigilance function is the early detection of a downturn in a patient’s health status or the advent of an adverse event, and the initiation of activities to “rescue” the patient and restore health. When this does not happen, “failure to rescue” is said to occur. The concept of failure to rescue has been tested and validated as an indicator of the quality of acute hospital care for surgical patients (Silber et al., 1992). When higher levels of nurse staffing are present, the incidence of failure to rescue is reduced (Aiken et al., 2002; Needleman et al., 2002). Further evidence of the effectiveness of nurse surveillance is found in studies of medication errors. A systems analysis of 334 medication errors associated with 264 preventable adverse events occurring in two hospitals over a 6-month period revealed that nurses were the health care personnel most likely to intercept errors in the ordering of a medication by a physician, the transcription of the drug order by a clerk, or the dispensing of the drug by a pharmacist before such errors resulted in an adverse event. Nearly half of all physician errors examined in this study had been intercepted before they resulted in an adverse event; 87 percent of those interceptions were by nurses. About one-third of transcription and dispensing errors had been