tee also commissioned papers and received expert testimony. (Appendix A contains a description of the committee’s membership and the process used to conduct this study.)

This process revealed that identifying and remediating latent factors in the work environment of nurses and increasing patient safety are not likely to be achieved by any single action. Instead, it will be necessary to implement bundles of mutually reinforcing practices—changes that support each other in altering the context of worker behavior within a work environment. Such bundles of changes are needed within each of the four fundamental components of all organizations: (1) management and leadership, (2) workforce deployment, (3) work processes, and (4) organizational culture. The changes needed in each of these components are essential to building stronger patient safety defenses in HCOs. Evidence also indicates that they are basic to efficient organization practices in the twenty-first century and to recruitment and retention of nurses in a time of nursing shortages, and indeed are fundamental to the effective deployment of all health care workers, not just nurses. However, evidence further indicates that many of these fundamental changes have not yet occurred in the work environments of nurses; thus there is a need not merely for small changes in those environments, but for a broad transformation.

Many individual aspects of the necessary transformation in these four bundles of practices are identified in To Err Is Human (IOM, 2000) and Crossing the Quality Chasm (IOM, 2001). This report is intended to serve as a companion to those earlier reports. It delves more deeply into some of their recommendations, and addresses some issues not discussed in those reports, such as worker fatigue and staffing levels. It also emphasizes the role health care organizations can play in increasing patient safety—a role addressed less fully in To Err Is Human and Crossing the Quality Chasm (Berwick, 2002; IOM, 2001).

In Chapter 2, we focus on the underlying framework linking the needed bundles of changes in management and leadership, workforce deployment, work processes, and organizational culture. We also describe further how this report relates to To Err Is Human and Crossing the Quality Chasm. Chapter 3 describes the characteristics of the nursing workforce and its work that are important factors in reshaping nursing work environments. Chapters 4 through 7 address the above four organizational components and the evidence base supporting the committee’s recommendations for change: Chapter 4 examines the need for evidence-based management and leadership; Chapter 5 calls for strengthening workforce capability; Chapter 6 speaks to the need to design nurses’ work and workspace to prevent errors; and Chapter 7 describes the need to create and sustain cultures of safety within organizations. Finally, Chapter 8 reviews the study findings in light of the turbulence that is characteristic of the U.S. health care system. It



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