KEEPING PATIENTS SAFE

Transforming the Work Environment of Nurses

Committee on the Work Environment for Nurses and Patient Safety

Board on Health Care Services

Ann Page, Editor

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Keeping Patients Safe: Transforming the Work Environment of Nurses KEEPING PATIENTS SAFE Transforming the Work Environment of Nurses Committee on the Work Environment for Nurses and Patient Safety Board on Health Care Services Ann Page, Editor INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Keeping Patients Safe: Transforming the Work Environment of Nurses THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services. The views presented in this report are those of the Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety and are not necessarily those of the funding agency. Library of Congress Cataloging-in-Publication Data Keeping patients safe : transforming the work environment of nurses / Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services ; Ann Page, editor. p. ; cm. ISBN 0-309-09067-9 (hardcover) 1. Nursing—Safety measures. 2. Work environment—Safety measures. 3. Industrial safety. 4. Nursing errors—Prevention. 5. Medical care—Quality control. 6. Nurse and patient. [DNLM: 1. Safety Management—organization & administration. 2. Nurse’s Role. 3. Nursing Care—organization & administration. 4. Workplace—organization & administration. WX 185 K26c 2004] I. Page, Ann. II. Institute of Medicine (U.S.). Board on Health Care Services. Committee on the Work Environment for Nurses and Patient Safety. RT87.S24K447 2004 362.17’3—dc22 2003022651 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin.

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Keeping Patients Safe: Transforming the Work Environment of Nurses “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe. INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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Keeping Patients Safe: Transforming the Work Environment of Nurses THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Keeping Patients Safe: Transforming the Work Environment of Nurses COMMITTEE ON THE WORK ENVIRONMENT FOR NURSES AND PATIENT SAFETY DONALD M. STEINWACHS (Chair), Professor and Chair of the Department of Health Policy and Management in the Johns Hopkins University Bloomberg School of Public Health ADA SUE HINSHAW (Vice Chair), Professor and Dean of the School of Nursing at the University of Michigan JOY DURFEE CALKIN, Professor Emeritus of Nursing at the University of Calgary, Canada, and health care consultant MARILYN P. CHOW, Vice President for Patient Care Services in the Program Office of Kaiser Permanente PAUL D. CLAYTON, Chief Medical Informatics Officer at Intermountain Health Care, Professor of Medical Informatics at the University of Utah, and Professor Emeritus at Columbia University MARY LOU DE LEON SIANTZ, Professor and Associate Dean for Research at the Georgetown University School of Nursing and Health Studies in Washington, D.C. CHARLENE A. HARRINGTON, Professor of Sociology and Nursing in the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco DAVID H. HICKAM, Professor in the Department of Medicine of the Oregon Health and Science University and a staff physician at the Portland Veterans Affairs Medical Center GWENDYLON E. JOHNSON, Staff Nurse in women’s health at Howard University Hospital in Washington, D.C. DAVID A. KOBUS, Certified Professional Ergonomist with the Pacific Science and Engineering Group in San Diego and involved in human performance research and project management for over 19 years ANDREW M. KRAMER, Professor of Medicine and Head of the Division of Health Care Policy and Research in the Department of Medicine at the University of Colorado PAMELA H. MITCHELL, Associate Dean for Research and Professor of Biobehavioral Nursing and Health Care Systems at the University of Washington School of Nursing AUDREY L. NELSON, Director of the Veterans Health Administration (VHA) Patient Safety Center of Inquiry, VHA Health Services Research Enhancement Program on Patient Safety Outcomes, and Associate Director for Clinical Research at the University of South Florida College of Nursing EDWARD H. O’NEIL, Professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco

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Keeping Patients Safe: Transforming the Work Environment of Nurses WILLIAM P. PIERSKALLA, Professor in the Department of Decisions, Operations, and Technology Management in the Anderson Graduate School of Management at the University of California, Los Angeles KARLENE H. ROBERTS, Professor in the Haas School of Business at the University of California at Berkeley, where she researches and consults on organizational behavior and industrial relations as they pertain to safety issues DENISE M. ROUSSEAU, H. J. Heinz II Professor of Organizational Behavior at Carnegie Mellon University, jointly in the Heinz School of Public Policy and Management and the Graduate School of Industrial Administration WILLIAM C. RUPP, President and Chief Executive Officer of Immanuel St. Joseph’s–Mayo Health System and Vice Chair of the Mayo Health System Study Staff ANN E. K. PAGE, Study Director and Senior Program Officer, Board on Health Care Services STELLA OPARA, Senior Project Assistant Health Care Services Board JANET M. CORRIGAN, Director ANTHONY BURTON, Administrative Assistant TERESA REDD, Financial Associate

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Keeping Patients Safe: Transforming the Work Environment of Nurses Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: DONNA DIERS, Yale University School of Nursing, New Haven, Connecticut COLLEEN GOODE, University of Colorado Hospital, Denver, Colorado KERRY KILPATRICK, University of North Carolina at Chapel Hill, North Carolina NANCY LANGSTON, Virginia Commonwealth University, Richmond, Virginia ELAINE LARSON, Columbia University, New York, New York MITCHELL RABKIN, Harvard Medical School, Boston, Massachusetts JAMES REASON, Disley, Cheshire, United Kingdom VINOD SAHNEY, Henry Ford Health System, Detroit, Michigan

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Keeping Patients Safe: Transforming the Work Environment of Nurses FRANCOIS SAINFORT, Georgia Institute of Technology, Atlanta, Georgia ROBYN STONE, Institute for the Future of Aging Services, Washington, D.C. MARY WAKEFIELD, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by ENRIQUETA BOND, Burroughs Wellcome Fund, Research Triangle Park, North Carolina, and GAIL L. WARDEN, Henry Ford Health System, Detroit, Michigan. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Keeping Patients Safe: Transforming the Work Environment of Nurses Foreword This report adds to our understanding of how to keep patients safe from the combined effects of the complexities of our technologically driven, compartmentalized, health care system and the fallibility of human health care providers, managers, and leadership within that system. Two prior Institute of Medicine reports—To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century—provide strong evidence on how the health care delivery system should be modified to compensate for these two error-conducive attributes. They speak to how the experiences of patients should be changed, how teams of health care workers should interact, how health care organizations can better design work and institute proactive error-reduction strategies, and how policy officials and health care purchasers can reshape health policy to create a safer health care system. The present report builds on these prior studies by examining patient safety from a new perspective—the characteristics of the work environment in which patient care is provided. It does so from the vantage point of the largest component of the health care workforce and a critical element of our health care system—nurses. When we are hospitalized, in a nursing home, or managing a chronic condition in our own homes—at some of our most vulnerable moments—nurses are the health care providers we are most likely to encounter, spend the greatest amount of time with, and be dependent upon for our recovery. Nursing actions such as ongoing monitoring of patient health status have been shown to be directly related to better patient outcomes. In their other roles, nurses intercept health care errors before they can adversely affect patients. When there are not enough nurses in a hospital to monitor pa-

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Keeping Patients Safe: Transforming the Work Environment of Nurses tients and provide therapeutic care, hospitals are forced to close beds, restrict admissions, and divert patients in need of emergency services, and patients are placed at risk. Good health care requires a nursing workforce appropriate in size and expertise, and unconstrained in its ability to provide patient care safely. This report presents guidance on how to design nurses’ work environments to enable them to provide safer patient care. It does so by explaining in detail how health care organizations should implement key recommendations of To Err Is Human and Crossing the Quality Chasm, examining aspects of work environments not addressed in those prior reports, and unifying the evidence from the two prior reports and this report into a strong framework for building work environments that promote the practice of safe nursing care. All health care organizations can follow this framework and the report’s recommendations to construct work environments more conducive to patient safety. Because of the centrality of nursing care in achieving good patient outcomes, patient safety demands that the recommendations in this report be adopted by all health care organizations, labor organizations, nursing schools, governmental agencies, and nurses themselves. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine November 4, 2003

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Keeping Patients Safe: Transforming the Work Environment of Nurses Preface Throughout this report, evidence is presented describing the critical role of nurses in the U.S. health care system. Nurses monitor patients’ status, coordinate their care, educate them and their families, and provide essential therapeutic care. This report also documents the many changes that have taken place in health care delivery over the last two decades that have affected the way in which nurses provide this care and keep patients safe from the inevitable health care errors so well documented in an earlier Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System. The Committee on the Work Environment for Nurses and Patient Safety identified plentiful threats to patient safety arising from every level and component of health care delivery, including the work processes, workload, work hours, and workspaces of nursing staff. Fortunately, the committee also identified findings from health services, nursing, organizational, and industrial research, as well as other empirical information on error production and prevention in a variety of industries, that provide clear guidance about how to reduce such threats. While the committee was not charged to, and did not, address the current nursing shortage in the United States, it was mindful of this situation in developing its recommendations. While nursing shortages in this country tend to be recurrent, federal government analyses show a growing discrepancy between the supply of and demand for registered nurses. This shortage is predicted to worsen in the near future, fueled by a projected 18 percent growth in the U.S. population between 2000 and 2020 and a 65 percent

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Keeping Patients Safe: Transforming the Work Environment of Nurses growth in the population over age 65, which requires a disproportionately larger share of health care services. In the face of the current and projected nursing shortage, the committee believes it is even more imperative that nurses’ work and work environments be designed to facilitate the safe delivery of nursing care. If the supply of nurses is to be stretched thin, nurses must be supported by work processes, workspaces, work hours, staffing, and organizational cultures that better defend against the commission of errors and readily detect and mitigate errors when they occur. It may be tempting to think that these recommendations can wait for increases in the supply of nurses, but evidence on how better to retain nurses indicates that the converse is true. Nurses are more likely to stay in health care organizations that implement many of the management, workforce, and work design practices recommended in this report. It is our hope that this report’s recommended framework, actions, and material presented in two appendixes on safe work hours and interdisciplinary collaboration and team functioning will be useful tools to all health care organizations, labor organizations, policy officials, educators, and nurses who seek to create safer health care delivery. While this study focuses on nurses, predominantly in hospitals and nursing homes, many of the committee’s recommendations are applicable to the work environments of all health care workers. Implementing these recommendations can greatly advance the safety of all individuals receiving health care. Donald M. Steinwachs, Ph.D. Ada Sue Hinshaw, Ph.D., R.N. Chair Vice Chair November 4, 2003 November 4, 2003

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Keeping Patients Safe: Transforming the Work Environment of Nurses Acknowledgments The Committee on the Work Environment for Nurses and Patient Safety thanks the many individuals who generously contributed their time, knowledge, and expertise to this study. We are especially indebted to the nurses who shared with us patient safety stories that are either excerpted or originally presented in this report. Their forthrightness helps us all see clearly the real-life implications of the issues addressed in this report. Bonnie Jennings, RN, Ph.D., American Academy of Nursing/American Nurses Foundation Scholar-in-Residence at the Institute of Medicine, also contributed her strong knowledge of nursing, a literature review, and her writing skills to Chapter 3 of this report. Lieutenant Colonel Rachel Armstrong RN, U.S. Army Nurse Corps, additionally provided much assistance in literature review and analyses for several chapters of the report. The committee commissioned nine papers to provide background information for its deliberations and to synthesize the evidence on particular issues. We thank Julie Sochalski, Ph.D., of the University of Pennsylvania School of Nursing for her paper, “The Nursing Workforce: Profile, Trends, Projections”; Barbara Mark, Ph.D., of the University of North Carolina at Chapel Hill School of Nursing for her paper, “The Work of Registered Nurses, Licensed Practical Nurses, and Nurses Aides in Acute Care Hospitals”; Barbara Bowers, Ph.D., of the University of Wisconsin-Madison School of Nursing Studies for her paper, “The Work of Nurses and Nurse Aides in Long Term Care Facilities”; Karen Martin of Martin Associates for her paper, “The Work of Nurses and Nursing Assistants in Home Care, Public Health, and Other Community Settings”; Ann Rogers, Ph.D., of the University of Pennsylvania School of Nursing for her paper, “Work Hour

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Keeping Patients Safe: Transforming the Work Environment of Nurses Regulation in Safety-Sensitive Industries”; Gail Ingersoll, Ed.D., and Madeline Schmitt, Ph.D., both of the University of Rochester Medical Center, for their paper, “Interdisciplinary Collaboration, Team Functioning, and Patient Safety”; Ann Hendrich of Ascension Health and Nelson Lee of Rapid Modeling, Inc. for their paper, “Evidence-based Design of Nursing Workspace in Hospitals”; Pascale Carayon, Ph.D., Carla Alvarado, Ph.D., and Ann Hundt, Ph.D., all of the University of Wisconsin-Madison Department of Industrial Engineering, for their paper, “Reducing Workload and Increasing Patient Safety Through Work and Workspace Design”; and Murat Bayiz of the Anderson School of Management at the University of California, Los Angeles, for his paper, “Work and Workload Measurements in Nurse Staffing Models.” Many individuals and organizations also presented testimony to the committee on aspects of nurses’ work environments that likely affect patient safety and potential improvements. We thank Barbara Blakeney, President of the American Nurses Association; Linda Burnes Boltin, Dr.P.H., of the American Academy of Nursing; Kathleen Long, Ph.D., President of the American Association of Colleges of Nursing; Phil Authier, President of the American Organization of Nurse Executives; Eileen Zungolo, Ed.D., President of the National League for Nursing; Jeanne Surdo, Secretary-Treasurer of United American Nurses; Martha Baker, President of the Service Employees International Union, Local 1991; Katherine Cox, Policy Analyst with the American Federation of State, County, and Municipal Employees; Gerry Shea, Assistant to the President for Government Affairs at the AFL-CIO; Jim Bentley, Senior Vice President for Strategic Policy Planning for the American Hospital Association; Steven Chies, Vice Chair of the American Health Care Association; Robin Stone, Ph.D., Executive Director of the Institute for the Future of Aging Services, an affiliate of the American Association of Homes and Services for the Aging; Tim Flaherty, M.D., of the American Medical Association and National Patient Safety Foundation; Steven Edelstein, J.D., of the Paraprofessional Institute; Donna Lenhoff, Esq., Executive Director of the National Citizens Coalition for Nursing Home Reform; Dennis O’Leary, President, and Margaret van Amringe, Vice President for External Relations, both of the Joint Commission on Accreditation of Healthcare Organizations; Cathy Rick, Chief Nursing Officer of the U.S. Department of Veterans Affairs; Sean Clarke, RN, Ph.D., of the University of Pennsylvania Center for Health Outcomes and Policy Research; Caryl Lee, RN, Program Manager for the National Center for Patient Safety of the U.S. Department of Veterans Affairs; Joyce Berger, Senior Advisor at the Health Technology Center; Daved van Stralen, M.D., Medical Director of Totally Kids® Specialty Healthcare, the American Association of Critical Care Nurses; Philip Greiner, past Chair, and Sonda Oppewal, Chair, of the Public Health Nursing Section of the American

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Keeping Patients Safe: Transforming the Work Environment of Nurses Public Health Association; Laurence Wellikson, Executive Director, and Janet Nagamine of the National Association of Inpatient Physicians; and John Hoff, Deputy Assistant Secretary for Disability, Aging, and Long Term Care Policy, and Jennie Harvel and Marvin Feuerberg, both Senior Policy Analysts, all with the U.S. Department of Health and Human Services. We also thank Paul Ginsburg, Ph.D., President of the Center for Studying Health System Change, and Cheryl Peterson of the American Nurses Association. At the Institute of Medicine, we would especially like to thank Bill McLeod, Adrienne Davis, Roberta Gooding, and all the staff of the George E. Brown Jr. Library for their patience and expert assistance in voluminous reference retrieval and formatting. Gooloo Wunderlich and Karen Adams of the Board on Health Care Services offered their wisdom and guidance throughout multiple stages of this study. Tony Burton was ever ready with his expert logistical support and problem-solving abilities, and Sue Barron ensured that this study complied with all Institute of Medicine study procedures. Bronwyn Schrecker at the Institute of Medicine and Jennifer Pinkerman at the National Research Council facilitated the external review process with great efficiency and attention to detail. We are very grateful to them all. Rona Briere of Briere Associates, Inc. provided expert editorial assistance and Alisa Decatur excellent proofreading and manuscript preparation assistance. Finally, we thank the Agency for Healthcare Research and Quality, whose funding made this study possible. We especially thank Helen Burstin, M.D., Director of the Center for Primary Care Research, and Sally Phillips, RN, Ph.D., Nurse Scholar within that center, for their very valuable insights and assistance.

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Keeping Patients Safe: Transforming the Work Environment of Nurses Contents     EXECUTIVE SUMMARY   1 1   NURSING: INSEPARABLY LINKED TO PATIENT SAFETY   23      Thousands of Health Care Errors,   24      Why Health Care Errors Occur,   27      The Central Role of Nurses in Patient Safety,   31      Patient Safety Risk Factors in Nurses’ Work and Work Environments,   37      Threats to Patient Safety Posed by Work Environment Factors,   46      Transforming Nurses’ Work Environments: Essential to Patient Safety,   47      References,   49 2   A FRAMEWORK FOR BUILDING PATIENT SAFETY DEFENSES INTO NURSES’ WORK ENVIRONMENTS   53      Building on To Err Is Human and Crossing the Quality Chasm,   53      The Need for Bundles of Multiple, Mutually Reinforcing Patient Safety Defenses,   55      An Evidence-Based Model for Safety Defenses in Work Environments,   56      Unique Features of Health Care That Have Implications for Patient Safety Defenses,   61      References,   63

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Keeping Patients Safe: Transforming the Work Environment of Nurses 3   NURSES CARING FOR PATIENTS: WHO THEY ARE, WHERE THEY WORK, AND WHAT THEY DO   65      Who Is Doing the Work of Nursing?,   65      Where Nurses Work,   76      What Nurses Do,   89      References,   101 4   TRANSFORMATIONAL LEADERSHIP AND EVIDENCE-BASED MANAGEMENT   108      Transformational Leadership: The Essential Precursor,   109      Five Essential Management Practices,   112      Uneven Application of Evidence-Based Management Practices in Nurses’ Work Environments,   131      Models of Evidence-Based Management in Nurses’ Work Environments,   147      Use of Evidence-Based Management Collaboratives to Stimulate Further Uptake,   153      References,   156 5   MAXIMIZING WORKFORCE CAPABILITY   162      Promoting Safe Staffing Levels,   163      Supporting Knowledge and Skill Acquisition and Clinical Decision Making,   201      Fostering Interdisciplinary Collaboration,   212      References,   218 6   WORK AND WORKSPACE DESIGN TO PREVENT AND MITIGATE ERRORS   226      Design of Work Hours,   227      Design of Work Processes and Workspaces,   239      References,   277 7   CREATING AND SUSTAINING A CULTURE OF SAFETY   286      Essential Elements of an Effective Safety Culture,   287      Need for a Long-Term Commitment to Create a Culture of Safety,   295      Barriers to Effective Safety Cultures from Nursing and External Sources,   299      Progress in Creating Cultures of Safety,   303      Need for All HCOs to Measure Their Progress in Creating Cultures of Safety,   307      Recommendations,   309      References,   310

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Keeping Patients Safe: Transforming the Work Environment of Nurses 8   IMPLEMENTATION CONSIDERATIONS AND NEEDED RESEARCH   312      Health Care Organizations and Other Parties Should Not Wait to Act,   313      Multiple, Mutually Reinforcing Safeguards Are Needed,   315      Benefits in Addition to Patient Safety Are Likely,   316      Additional Research Is Required to Further Increase Patient Safety,   322      Recommendation,   325      References,   325     APPENDIXES     A   COMMITTEE MEMBERSHIP AND STUDY APPROACH   329 B   INTERDISCIPLINARY COLLABORATION, TEAM FUNCTIONING, AND PATIENT SAFETY   341 C   WORK HOUR REGULATION IN SAFETY-SENSITIVE INDUSTRIES   384     INDEX   437

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Keeping Patients Safe: Transforming the Work Environment of Nurses Tables, Figures, and Boxes TABLES 3-1   Primary Employment Settings of RNs Employed in Nursing, 2000,   77 3-2   Employment Settings of NAs, 1999,   77 3-3   Types of Work Units in Which Hospital-Employed RNs Spend More Than Half of Their Direct Patient Care Time,   78 5-1   Variations in Nurse-to-Patient Ratios in Pennsylvania Hospitals, 1999,   173 5-2   Types of Work Units in Which Hospital-Employed RNs Spend More Than Half of Their Direct Patient Care Time,   173 5-3   Nurse Staffing Estimates Derived from Staffing Studies,   175 5-4   Average Number of Patients per RN, by Shift and Rural/Nonrural Location, in California,   177 5-5   Quartiles of Staffing Data in Medical–Surgical Units, in California,   177 5-6   California Hospital Nurse-to-Patient Ratios: Means, Medians, and Quartiles (1998–1999),   178 5-7   Types and Average Length of Orientation Programs for Newly Licensed RNs,   204 6-1   Seven Categories of Waste as Applied to the Hospital Environment,   259 6-2   Workspace Design Elements for General Patient Care Rooms Based on LEAN Principles,   270

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Keeping Patients Safe: Transforming the Work Environment of Nurses C-1   A Comparison of Work Hour Limitations in Selected Safety-Sensitive Industries,   418 FIGURES ES-1   Sources of threats to patient safety in the work environment and corresponding safety defenses,   19 2-1   The basic elements of production,   58 2-2   Human contributions to error within each production component,   59 2-3   Basic work production components of all organizations and corresponding patient safety defenses,   60 5-1   Total nurse staffing hours per resident in all U.S. nursing facilities, 1993–2001,   179 6-1   Scheduled and actual shift durations,   235 7-1   A Decision Tree for determining the culpability of unsafe acts,   304 BOXES ES-1   Necessary Patient Safeguards in the Work Environment of Nurses,   16 1-1   Patient Monitoring in an Intensive Care Unit: An Example,   33 3-1   The Benefits of RN Surveillance: A Case Example,   92 3-2   Time Required for Emotional Support: A Case Example,   98 4-1   The Toyota Production System,   126 7-1   Litigation and Regulatory Barriers to Effective Safety Cultures: Two Case Examples,   302 8-1   Necessary Patient Safeguards in the Work Environment of Nurses,   314

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