Copyright © National Academy of Sciences. All rights reserved.
This executive summary plus thousands more available at http://www.nap.edu
Keeping Patients Safe: Transforming the Work Environment of Nurses
http://books.nap.edu/catalog/10851.html
2 KEEPING PATIENTS SAFE
In this context, and in recognition of evidence on the key role of nurses
in patient safety, the U.S. Department of Health and Human Services’
(DHHS) Agency for Healthcare Research and Quality (AHRQ) asked the
IOM to conduct a study to identify:
• Key aspects of the work environment for nurses that likely have an
impact on patient safety.
• Potential improvements in health care working conditions that would
likely increase patient safety.
AHRQ further directed that the study be conducted “in the context of cur-
rent policy debates on regulation of nursing work hours and nursing
workload . . . [and] cover such topics as: extended work hours and fatigue,
including mandatory overtime; workload issues, including state regulation
of nurse-to-bed ratios; workplace environmental issues, including poorly
designed care processes; . . . workplace systems, including reliance on
memory and lack of support systems for decision-making; and workplace
communication, including social, physical, and other barriers to effective
communication among care team members.” The IOM convened the Com-
mittee on the Work Environment for Nurses and Patient Safety to conduct
this study.
THE CRITICAL ROLE OF NURSES IN PATIENT SAFETY
The 2.8 million licensed nurses and 2.3 million nursing assistants pro-
viding patient care in this country represent approximately 54 percent of all
health care workers and provide patient care in virtually all locations in
which health care is delivered—hospitals; nursing homes; ambulatory care
settings, such as clinics or physicians’ offices; private homes; schools; and
employee workplaces. When people are hospitalized, in a nursing home,
having a baby, or learning to manage a chronic condition in their own
home—at some of their most vulnerable moments—nurses are the health
care providers they are most likely to encounter; spend the greatest amount
of time with; and, along with other health care providers, depend on for
their recovery.
Research is now beginning to document what physicians, patients, other
health care providers, and nurses themselves have long known: how well
we are cared for by nurses affects our health, and sometimes can be a mat-
ter of life or death. As physicians in the American College of Critical Care
Medicine have noted: “Critical care nurses do the majority of patient as-
sessment, evaluation, and care in the ICU [intensive care unit]” (Brilli et al.,
2001:2011). Nursing actions, such as ongoing monitoring of patients’ health
status, are directly related to better patient outcomes (Kahn et al., 1990;

Copyright © National Academy of Sciences. All rights reserved.
This executive summary plus thousands more available at http://www.nap.edu
Keeping Patients Safe: Transforming the Work Environment of Nurses
http://books.nap.edu/catalog/10851.html
14 KEEPING PATIENTS SAFE
Creating and Sustaining a Culture of Safety
Employing a nursing workforce strong in numbers and capabilities and
designing their work to prevent errors will not be sufficient to fully safe-
guard patients. The largest and most capable workforce is still fallible, and
the best-designed work processes are still designed by fallible individuals.
Patient safety also requires an organizational commitment to vigilance to
prevent potential errors, and to the detection, analysis, and redress of errors
when they occur.
A variety of safety-conscious industries have made such a commitment
and achieved substantially lower rates of errors by doing so. These organi-
zations place as high a priority on safety as they do on production; all
employees are fully engaged in the process of detecting high-risk situations
before an error occurs. Management is so responsive to employees’ detec-
tion of risk that it dedicates time, personnel, budget, and training resources
to bring about changes needed to make work processes safer. Employees
also are empowered to act in dangerous situations to reduce the likelihood
of adverse events. These attitudes and employee engagement are so perva-
sive and observable in the behaviors of these organizations and their em-
ployees that an actual culture of safety exists within the organization. These
organizational cultures are effective because they (1) recognize that the
majority of errors are created by systemic organizational defects in work
processes, not by blameworthy individuals; (2) support staff; and (3) foster
continuous learning by the organization as a whole and its employees.
HCOs should redouble their efforts to create such cultures of safety
within their work environments. Such efforts require a long-term commit-
ment because they necessitate changes in the attitudes and behaviors of
both organizations and people. Time is needed to enact an initial change,
evaluate, refine, and enact further change. Strong organizational leadership
is also essential. The safety of patients needs to be a stated and visible prior-
ity, with every organizational member understanding that each is fallible,
even with the best of intentions, as are the processes used. Moreover, estab-
lishing a fair and just culture in responding to errors reduces workers’ fear
and disincentives to report errors and near misses. As a result, all nursing
staff are more inclined to be vigilant for errors and near misses, with a view
toward learning from each event and strengthening the culture of safety
accordingly. Action also is needed from state boards of nursing and Con-
gress to enable strong and effective cultures of safety to exist. To these ends,
the committee makes the following recommendations:
Recommendation 7-1. HCO boards of directors, managerial lead-
ership, and labor partners should create and sustain cultures of
safety by implementing the recommendations presented previously
and by: