JCAHO: Casualties tied to gaps in nursing

[NRSKarenRN, BSN, RN]

the joint commission on accreditation of healthcare organizations says in a new report that inadequate nurse staffing contributes to nearly a quarter of hospital incidents that kill or injure patients. estimates are that 98,000 deaths a year can be blamed on medical errors, and 10 percent of nursing jobs are currently empty.

boston globe, aug. 7, 2002

http://www.boston.com/dailyglobe2/219/nation/casualties_tied_to_gaps_in_nursing+.shtml

casualties tied to gaps in nursing

hospital data cited in report on injury, death

by anne barnard, globe staff, 8/7/2002

inadequate nurse staffing contributes to nearly a quarter of hospital incidents that kill or injure patients, the national group that accredits hospitals says in a report being released today. the group called on the federal government and the health-care industry to act more aggressively on the growing shortage of registered nurses.

the report suggests that the shortage of nurses is a factor in tens of thousands of deaths annually from causes ranging from medication errors to patient falls and hospital-acquired infections. nationally, 98,000 deaths a year have been blamed on medical errors, and one in 10 nursing jobs is currently empty.

''there's a problem out there,'' said dr. dennis o'leary, president of the joint commission on accreditation of healthcare organizations. ''we knew other people were going to gulp and say, `that's really high.'''

the commission is a private group that inspects and accredits hospitals. nurses unions and patient groups have sometimes called it too friendly to hospital administrations.

the commission based its findings on the hospitals' assessments of unexpected adverse outcomes that either killed patients or caused them serious physical or psychological harm. of the 1,609 adverse events that hospital officials voluntarily reported to the commission between january 1996 and march 2002, 24 percent took place in part because hospitals had an insufficient number of registered nurses on the job, according to hospital officials.

despite increasing public attention to both medical errors and the nursing shortage, neither hospitals nor the government have reacted strongly enough, said o'leary.

he called for more federal spending to train and support nurses and to encourage hospitals to increase staffing with incentives such as tying extra medicare and medicaid payments to improved nurse staffing and better patient outcomes.

''there seems to be a tacit belief that where we are now is ok,'' he said. ''we're saying somebody ought to be really bothered about this right now, and it's probably going to get worse if we don't wake up.''

there are now 126,000 unfilled nursing positions in the united states. nursing specialist peter buerhaus, who helped write the commission's report, has predicted a shortage of 500,000 registered nurses by 2020; a federal report issued last month put the number at 800,000. a study published in health affairs magazine said that only 34 percent of registered nurses believe their hospitals have adequate nursing staff and that 83 percent said the number of patients in their care had increased.

the shortage of nurses is particularly worrisome because research increasingly shows a link between the staffing shortage and patient recovery. for instance, recent studies showed that increased nurse staffing is associated with fewer urinary tract infections and cases of pneumonia, as well as lower mortality. in another study, patients who had abdominal aortic surgery in hospitals with fewer intensive-care nurses had longer hospital stays and more complications.

the report by the joint commission on accreditation was produced by a panel of academics, nurse executives, and a union representative. it recommends a range of initiatives, from more federal scholarships for nurses to establishing training regimens akin to doctors' residencies. and it argues that the cost of such changes will be offset by reducing the amount hospitals must spend to replace nurses who quit over adverse working conditions.

o'leary, an internist, said he believes that the reports hospitals voluntarily submit to the commission are representative of all medical errors and that a quarter of the 98,000 deaths attributed to medical errors each year could be caused by staffing issues.

hospital executives did not dispute the data. ''now we have data to really demonstrate that this ... affects patient care,'' said jeanette clough, a registered nurse and president of mount auburn hospital, which temporarily closed two of its 10 intensive-care beds last year because of inadequate staffing.

the commission's figures may understate the effect of the nursing shortage on adverse medical events, o'leary said, because medication errors are often underreported and because hospitals may blame some of them on miscommunication or insufficient training that could also be related to staffing levels.

in proposing solutions, the commission is wading into a longstanding debate over levels of staffing. hospitals say they have fallen victim to workplace trends that have pulled people away from nursing, and they want more subsidies for nursing education and recruitment, like those in a $30 million bill that president bush signed last week.

but some nurses' groups say that hospitals created the shortage by laying off so many nurses in the mid-1990s that workloads became intolerable and nurses shied away from hospital employment, fearing they would make a fatal mistake. those groups are calling for laws specifying nurse-to-patient ratios, such as a law and regulations that took effect this year in california. a similar bill was filed in massachusetts last fall but has languished in committee.

the massachusetts nurses association, the state's largest nurses union, welcomed some of the suggestions in the commission's report, but said it did not go far enough, because it stopped short of endorsing ratios.

''jcaho was accrediting all these organizations for the last 15 years that purposely implemented staffing cutbacks and replaced nurses with less skilled people to save money,'' said julie pinkham, the union's executive director.

the commission accredits 80 percent of the nation's hospitals through site visits that hospitals usually know about in advance, with details kept private.

but the commission has recently vowed to get more aggressive. last month, it introduced regulations that require hospitals to track staffing issues such as overtime and clinical outcomes that are affected by staffing, such as infections and patient falls.

the commission also plans to take public-policy stances on problems such as hospitals' emergency preparedness and overcrowding of emergency rooms.

it addressed the nursing shortage first, o'leary said, because that was the issue ''that really curled our hair.''

anne barnard can be reached at [email protected].

this story ran on page a1 of the boston globe on 8/7/2002.

nursing shortage

nurse staffing levels were deemed a contributing factor in...

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50% of ventilator-related incidents.

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42% of surgery-related incidents.

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25% of transfusion incidents.

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25% of delays in treatment.

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25% of infant abductions.

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19% of medication errors.

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14% of inpatient suicides.

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14% of patient falls.

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sources: joint commission on accrediting healthcare organizations analysis of 1,609 incidents from 1996

through march 2002.

jcaho press release:

nursing shortage poses serious health care risk: joint commission expert panel offers solutions to national health care crisis

http://www.jcaho.org/news+room/news+release+archives/nursing+shortage.htm

full 47 page report:

health care at the crossroads: strategies for addressing the evolving nursing crisis

http://www.jcaho.org/news+room/news+release+archives/health+care+at+the+crossroads.pdf

[NRSKarenRN, BSN, RN]

based on those discussions, the following recommendations are proposed for transforming the workplace, aligning nursing education and clinical experience, and providing financial incentives for health care organizations to invest in high

quality nursing care. pg. 6 of report; highlights below on page 7

http://www.jcaho.org/news+room/news+release+archives/health+care+at+the+crossroads.pdf

1. create organizational cultures of retention

adopt the characteristics of "magnet" hospitals

to foster a workplace that empowers and is

respectful of nursing staff. provide management

training, as well as support, to nurse executives.

positively transform nursing work through

the use of information and ergonomic

technologies. set staffing levels based on

nurse competency and skill mix relative to

patient mix and acuity. adopt zero-tolerance

policies for abusive behaviors by health care

practitioners. diversify the nursing workforce

to broaden the base of potential workers.

2. bolster the nursing educational infrastructure

increase funding for nursing education,

including endowments, scholarships and

federal appropriations. establish a standardized,

post-graduate nursing residency program.

emphasize team-training in nursing education.

enhance support of nursing orientation,

in-service and continuing education in

hospitals. create nursing career ladders

commensurate with educational level

and experience.

3. establish financial incentives for investing in nursing

make new federal monies available for health

care organizations to invest in nursing services.

condition continued receipt of these monies

on achievement of quantifiable, evidence-based,

and standardized nursing sensitive goals. align

private payer and federal reimbursement

incentives to reward effective nurse staffing.

.

[NRSKarenRN, BSN, RN]

Page 27 of Report: Create a Culture of Retention

Identifies tatics AND addresses accountability

#1: Minimize the paperwork and administrative burden that takes nursing time away from patient care.

Accountable:

JCAHO

Managed Care Companies

CMS, OSHA, and other regulators,

including State Agencies

[NRSKarenRN, BSN, RN]

See the Nursing Round table panelists and End notes for sources of info--- Even included Novenber 2001 Self Magazine article!!!!

Think we should send Thank you letters to Nursing Roundtable panelists!

[night owl]

I never could understand how such an organization could make a facility credible by saying that the ratios that are in place now are SAFE ratios. When staffing was cut to save money, what did they expect? Miracles? Of course when you cut corners you're going to have bad outcomes! How foolish could they have been?????

[NRSKarenRN, BSN, RN]

from page 37:

finally, in answer to the nurses intent on leaving the profession and those unwillingly to replace them, hospitals must create cultures of retention in their workplaces, and their successes in this regard must be documented and rewarded.

all of the recommendations in this paper are achievable.

if they are met, the future outlook for the nursing profession and for the provision of safe, high quality care in this nation's hospitals will brighten considerably.

[-jt]

JCAHO has spent the last year in meetings with staff nurses & our organizations, effectively getting an education on the subject - courtesy of staff RN & LPN nurses unions & the ANA. Suddenly, JCAHO gets it. The comments & solutions JCAHO has come up with echos some of what these nursing groups have been saying & pushing for for the past 3 years. Its about time JCAHO started paying attention. By all means send them a thank you for finally waking up & send a thank you to the nurses & their organizations who forced them to.

[nimbex, RN]

now if only joint commission will lighten up on the 10,000000000 requirements for documentation, we may have a bit more time to care for the paitents. ironic to me

[troublennc]

the study was a first step. However, as a new grad, new to a med surg unit (but not health care) and I am very disappointed in nurses that LET thier facility treat them like garbage. I cannot believe that nurses feel that helping people means that they should be worked like dogs, and then blame them for mistakes that would have been prevented if they had time to think. I have never put up with such bad working conditions and I can't believe that anyone would!!!

It time to stop this degrading cycle! I say thanks to the commision for at least bringing the issue to greater national attention.

[rncountry]

A great big thank you to Karen for continously striving to put meaningful information out there that the rest of us can use. Printing the entire report to take to the next campaign meeting I have on Monday. It is the perfect synopsis for what I need. Much appreciated.