Published Nov 6, 2003
from: cheryl peterson, msn, rn
senior policy fellow
department of nursing practice & policy
date: november 4, 2003
re: institute of medicine report, keeping patients safe: transforming the work environment of nurses
the agency for healthcare research and quality (ahrq) asked the institute of medicine (iom) to conduct a study to identify:
1) key aspects of the work environment for nurses that likely have an impact on patient safety.
2) potential improvements in health care working conditions that would likely increase patient safety.
in june 2002, the iom convened the committee on work environment for nurses and patient safety to conduct this study. on september 24, 2002, president blakeney, in testimony before the committee, made the following recommendations:
nurses must have decision-making authority and professional autonomy at the point of care delivery and in all arenas where decisions related to care delivery are made.
resources must be devoted to the development of systems that provide safe and appropriate nurse staffing levels.
all healthcare facilities and agencies should be required to participate in the collection and external reporting of standardized nursing-sensitive data b both to assess the sufficiency of staffing and to quantify the safety and quality of care for consumers and payors.
it is time to actively invest in research around staffing, fatigue, safety, and outcomes.
keeping patients safe builds on the 1999 iom report, to err is human: building a safer health system. it speaks to the critical role of nurses in providing patient care and preventing error. it also acknowledges that hospital restructuring and redesign initiatives, "have been focused largely on increasing efficiency and have been undertaken in ways that have damaged trust between nursing staff and management. changes often have been poorly managed so that intended results have not been achieved, infrequently have involved nurses in decision making pertaining to the redesign of their work, and have not employed practices that encourage the uptake and dissemination of knowledge throughout the organization." (page 4)
recommendations in the report are primarily focused on the hospital and nursing home settings and are structured under five (5) topical headings:
1. transformational leadership and evidence-based management
2. maximizing workforce capability
3. design of work and workspace to prevent and mitigate errors
4. creating and sustaining a culture of safety
5. additional research
the report may be accessed online at http://books.nap.edu/catalog/10851.html
recommendations in this section address the need for ongoing research around the delivery of health services and patient safety.
recommendation 8-1. federal agencies and private foundations should support research in the following areas to provide hcos with the additional information they need to continue to strengthen nurse work environments for patient safety:
* studies and development of methods to better describe, both qualitatively and quantitatively, the work nurses perform in different care settings.
* descriptive studies of nursing-related errors.
* design, application, and evaluation (including financial costs and savings) of safer and more efficient work processes and workspace, including the application of information technology.
* development and testing of a standardized approach to measuring patient acuity.
* determination of safe staffing levels within different types of nursing units.
* development and testing of methods to help night shift workers compensate for fatigue.
* research on the effects of successive work days and sustained work hours on patient safety.
* development and evaluation of models of collaborative care, including care by teams.
institute of medicine
committee on work environment for nurses and patient safety
donald steinwachs, phd, committee chair
professor and chair of the department of health policy and management, johns hopkins university bloomberg school of public health
ada sue hinshaw, phd, rn, faan vice chairperson
dean school of nursing, university of michigan
joy durfee caulkin, phd, professor emeritus of nursing at the university of calgary, canada and health care consultant.
marilyn chow, dns, rn, faan
vice president, patient care services, california division for kaiser permanente
paul clayton, phd
chief medical informatics officer, intermountain health care
professor medical informatics, university of utah
mary lou de leon siantz, rn, phd, faan
professor and associate dean for research, georgetown university school of nursing and health studies
charlene harrington, phd, rn, faan
professor of sociology and nursing, department of social and behavioral sciences, school of nursing, university of california, san francisco
david hickam, md, mph
professor, department of medicine, oregon health science university
staff physician, portland veterans affairs medical center
gwendylon johnson, ma, rnc
staff nurse, howard university hospital
david kobus, phd
certified professional ergonomist
andrew kramer, md
professor of medicine and head of the division of health care policy and research, department of medicine, university of colorado
pamela mitchell, phd, rn, faan
associate dean for research and professor of biobehavioral nursing and health care systems, university of washington school of nursing
audrey nelson, phd, rn, faan
director, veterans health administration (vha) patient safety center of inquiry
director, vha health services research on patient safety outcomes
director, suncoast development research evaluation center on safe patient transitions
edward o'neil, phd
professor of family and community medicine and dental public health, university of california at san francisco
director, center for the health professions
william pierskalla, phd
professor, department of operation and technology management, anderson graduate school of management, university of california at los angeles
karlene roberts, phd
professor, haas school of business, university of california at berkeley
denise rousseau, phd
h. j. heinz ii professor of organizational behavior, carnegie mellon university
professor, heinz school of public policy and management
professor, graduate school of industrial administration
william c. rupp, md
president and chief executive officer of immanuel st. joseph's-mayo health system
vice chair of the mayo health system
Los Angeles Times
November 5, 2003 Wednesday Home Edition
SECTION: Main News; Part 1; Page 30; National Desk
HEADLINE: The Nation;
Nursing Safety Net Frayed, Report Says;
Staffing shortages, poor conditions at facilities are called the greatest threats to patients.
BYLINE: Lisa Richardson, Times Staff Writer
Poor working environments in hospitals and nursing homes and a shortage of nurses are the greatest threats to patient safety, according to a report issued Tuesday by the Institute of Medicine of the National Academies.
"We're talking about an entire cultural change," said Ada Sue Hinshaw, a member of the committee that produced the report
"When there's an inadequate number of staff there are clear complications for patients. It is nurses who provide front line surveillance," said Hinshaw, dean of the University of Michigan School of Nursing at Ann Arbor.
The report, which comes amid a national nursing shortage, cites a study of two hospitals that found nurses intercepted 86% of medication errors before they reached patients.
The author of the report, Donald M. Steinwachs, chair of the department of health policy and management at the Bloomberg School of Public Health at Johns Hopkins University, said the powerful correlation between patient safety and adequate nursing makes changing current practices urgent.
"When you have workers who are spread too thin ... you are compromising patient safety," Steinwachs said.
In its recommendations, the medical advisory panel calls for mandatory scheduling and minimum staffing levels in nursing homes and intensive care units.
The Institute of Medicine issued a landmark report in 2000 that estimated as many as 98,000 hospitalized Americans die each year because of errors.
Tuesday's report cited studies that showed increased infections and cardiac and respiratory failure were associated with inadequate numbers of nurses.
The California Nurses' Assn., which fought for mandatory nurse-to-patient ratios that take effect in January, said the report boosted its position.
The California Healthcare Assn., which represents hospitals, asked how hospitals could beef up staffing when there are too few nurses.
Report Cites Danger in Long Nurses Hours
November 5, 2003
By ROBERT PEAR
WASHINGTON, Nov. 4 - Many hospitals and nursing homes are endangering patients by allowing or requiring nurses to work more than 12 hours a day, the National Academy of Sciences said on Tuesday.
Such long hours cause fatigue, reduce productivity and
increase the risk that the nurses will make mistakes that
harm patients, the academy said in a new report
commissioned by the federal government.
Donald M. Steinwachs, chairman of the health policy
department at Johns Hopkins University, said fatigue was a "major cause of mistakes and errors" in hospitals and nursing homes. Mr. Steinwachs was chairman of the panel of 18 experts who conducted the study.
The report said many nurses and nursing assistants worked
more than 12 consecutive hours, with some working double
shifts of 16 hours.
To reduce "error-producing fatigue," the report said, state officials should prohibit nurses from working more than 12 hours in any 24-hour period or more than 60 hours a week.
In one study for the government, 27 percent of nurses at hospitals and nursing homes reported that they worked more than 13 consecutive hours at least once a week.
The report, from the academy's Institute of Medicine, said, "Long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors."
Many hospitals and nursing homes have too few nurses to
take proper care of patients, the panel said.
Intensive care units at hospitals should have one licensed nurse on duty for every two patients, the report said. Nursing homes, it said, should have one registered nurse for every 32 patients and one nursing assistant for every 8.5 patients.
The Bush administration said last year that it had no plans
to set minimum staffing levels for nursing homes, in part because such requirements would generate billions of dollars in additional costs for Medicaid, Medicare and nursing homes.
But the National Academy of Sciences said the
administration should do what it declined to do last year:
set "minimum standards for registered and licensed nurse staffing in nursing homes."
The academy found overwhelming evidence that as levels of
nurse staffing rose the quality of care improved, because nurses had more time to monitor patients and can more readily detect changes in their conditions.
"Studies show that increased infections, bleeding and
cardiac and respiratory failure are associated with
inadequate numbers of nurses," the report said. "Nurses
also defend against medical errors. For example, a study in
two hospitals found that nurses intercepted 86 percent of medication errors before they reached patients."
Senator Charles E. Grassley, an Iowa Republican who has
been investigating nursing homes since 1997, said he saw no need for the government to specify the proper number of nurses.
"If we mandate minimum staffing levels, the nursing home industry will want more money," Senator Grassley said. "It seems nursing homes already receive plenty of money to do the job" - more than $58 billion a year from Medicare and Medicaid. Senator Grassley recently secured a promise from the industry to use $4 billion in Medicare money to improve services to patients in the next decade.
Dr. Andrew M. Kramer, a panel member who is a professor of medicine at the University of Colorado, said nursing assistants "work double shifts on a fairly regular basis" at some nursing homes.
The academy said the nation's 2.8 million licensed nurses
and 2.3 million nursing assistants accounted for 54 percent
of health care workers. Thus, said Dr. Harvey V. Fineberg, president of the Institute of Medicine, "It is nurses who deliver most of the care we receive."
But Dr. William C. Rupp, a member of the panel who is
president of a Mayo Health System hospital in Mankato,
Minn., said, "Virtually every other industry in the country pays more attention to fatigue than we do."
Pamela Thompson, chief executive of the American
Organization of Nurse Executives, a subsidiary of the
American Hospital Association, said it was "an accepted practice" for nurses to work 12-hour shifts.
Alan E. DeFend, vice president of the American Health Care Association, which represents nursing homes, said: "The shortage of nursing assistants has reached crisis proportions. Sometimes there's just no alternative to overtime."
The panel did not distinguish between voluntary and
Ada Sue Hinshaw, a panel member who is dean of the School
of Nursing at the University of Michigan, said: "The
fatigue effects are the same. Medical errors start climbing after 12 hours of work."
To reduce such errors, the panel said, nurses should be
more involved in the day-to-day management of hospitals and nursing homes.
hope you guys don't mind if I read it over a couple of times in order to really grasp all this info before commenting
NRSKarenRN, BSN, RN
Bumping for a second look + to see what changes have been implimented....
You know....I read the article To Err is human several months back and there is some portions that are actually making it into healthcare like the staffing ratios in ICU's being addressed. I know california has the 2-1 ratios mandated in law....but alot of their information just isnt making it into healthcare.
I think information that is dispersed to all disciplines is a must...yet there are still facilities that limit the "nurses" access to healthcare information r/t their current admission...like CT results....pathology reports....even some lab reports.And again....that plays into the safety aspect. Let's say you have a C&S of a wound that is done intraop and post op the wound is draining.If the urgery was done on a Thursday...it may be Monday before the word is provided via the MD that the patient is growing gram negative bacteria....maybe it's acinetobacterium or bacterial menningitis.Lapses in healthcare information is a huge safety risk .
And as far as the management aspect ...with trust being restored amongst employees.Alot of nurses feel like I do....bite me once -shame on you...bite me twice-shame on me!So trust....has to be earned by management...it is not freely given anyone bc too many of us have too many "bite " marks.Alot of us had trust in management at one time......but nowadays..........
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