inadequate nurse training and insufficient monitoring of patients because of too few nurses being assigned to patient care.

These findings are underscored by an analysis of data on serious health care errors that are reported to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) database on sentinel events. JCAHO defines a sentinel event as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (JCAHO, 2003:53). The JCAHO database is relatively small and subject to underreporting. Nevertheless, for 19 percent of the total errors reported to the database from 1995 to 2002, nurse staffing levels are cited as one of the four major causal factors for reported serious errors/adverse events, such as patient falls, medication and transfusion errors, delays in treatment, and operative and postoperative complications. Inadequate staff orientation and training and competency assessment, as well as breakdowns in communication, were also revealed as frequent contributors to errors; communication-related factors were the most frequently identified root cause of all types of sentinel events (Croteau, 2003).

Preventing errors associated with such conditions requires that strong defenses be built into the work environment of nurses. As noted by Reason (2000:769), “We cannot change the human condition, but we can change the conditions under which humans work.”


The evidence cited above and in succeeding chapters makes clear that (1) patient safety continues to be threatened; (2) latent conditions in work environments are the primary sources of those threats; and (3) nurses are the largest contingent of health care workers and perform critical patient safety functions while operating at the “sharp end” of health care. Given these facts, it is clear that the latent conditions present in the work environment of nurses must be addressed if patient safety is to be improved. This conclusion validates AHRQ’s charge to the IOM to identify key aspects of the work environment for nurses likely to have an impact on patient safety, and potential improvements in health care working conditions that would likely increase patient safety.

In carrying out this charge, the committee reviewed published research and other evidence from a variety of disciplines: health services and nursing research; behavioral and organizational research on work and workforce effectiveness; human factors analysis and engineering; studies of organizational disasters and their evolution; and studies of high-risk industries (e.g., nuclear power production, chemical processing, transportation) with low accident rates (often called “high-reliability organizations”). The commit-

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