Chapter 22. Practice Implications of Keeping 

Patients Safe 

Ann E. K. Page 

Background 

Improving patient safety and other dimensions of health care quality requires change at all 

four levels of the health care system: (1) the experience of patients during their interactions with 

individual clinicians; (2) the functioning of small units (microsystems) of care delivery such as 

surgical teams or nursing units; (3) the practices of organizations that house the microsystems; 

and (4) the environments of policy, payment, regulation, accreditation, and other factors external 

to the actual delivery of care that shape the context in which health care organizations deliver 

care.

1 Several groundbreaking Institute of Medicine (IOM) reports have spurred substantial 

actions at each of these levels to bring about improvements in patient safety and overall quality. 

These IOM reports began as the product of the unique Committee on the Quality of Health 

Care in America created by the IOM in 1998 in response to the accumulating number of studies 

documenting that the way in which health care has been delivered has not kept pace with the 

advances in medical technology and our growing knowledge about diseases and how to 

effectively treat them. The committee’s first report, To Err Is Human, was stunning. This report 

documented that not only was health care often of poor quality, it was actually unsafe. The report 

said that between 44,000 and 98,000 deaths every year (more than deaths from breast cancer, 

AIDS, or motor vehicle accidents) were caused by problems in the way the health care system 

was designed, not from “bad” doctors, nurses, or other health care workers.2

The report’s message and recommendations for building safer systems of care delivery across 

the entire U.S. health care system primarily addressed the changes needed at the fourth level of 

the health care system—where policy, payment, regulation, accreditation, and similar external 

factors shape the delivery of health care.a Within weeks of the report’s release, the Senate 

Committee on Appropriations began hearings on medical errors and patient safety. 

As a result of those hearings, Congress directed the Agency for Healthcare Research and 

Quality (AHRQ) to lead a national effort to combat medical errors and improve patient safety. 

AHRQ subsequently established a research and demonstration program to fund research to 

determine the causes of medical errors and to develop models that minimize the frequency and 

severity of errors; mechanisms that encourage reporting, prompt review, and corrective action; 

and methods to minimize paperwork.3

 

 

a

 The Committee’s second report, Crossing the Quality Chasm—A New Health System for the 21st Century,

addressed health care quality in all its dimensions: effectiveness, timeliness, patient centeredness, efficiency, and 

equity (in addition to safety). Crossing the Quality Chasm generally spoke to the first and second levels of the health 

care systems—the experiences of patients with their individual clinicians and the microsystems of care delivery. To 

Err Is Human and Crossing the Quality Chasm both directed less attention to the third level—health care 

organizations. 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Nurse Working Conditions 

Nursing personnel represent the largest component of the health care workforce. Licensed 

nurses and unlicensed nursing assistants represent approximately 54 percent of all U.S. health 

care workers (e.g., physicians, nurses, dentists, allied health professionals, technicians and 

technologists, and other health care assistants).4 Registered nurses (RNs) alone constitute 

approximately 23 percent of the entire health care workforce—the largest portion among all 

health care workers. These 2.2 million RNs provide health care to individuals in virtually all 

locations in which health care is delivered—hospitals; long-term care facilities; ambulatory care 

settings, such as clinics or physicians’ offices; and other settings, including the private homes of 

individuals, schools, and workplaces. In U.S. hospitals, approximately one of every four hospital 

employees is a licensed nurse.5 Although constituting the largest contingent in the health care 

workforce, nurses are in short supply and competition for them is strong. 

As part of its portfolio of research and demonstrations, AHRQ contracted with the IOM to 

study key aspects of the work environment of nurses that likely impact patient safety and identify 

potential improvements that would likely increase patient safety. AHRQ further directed the 

IOM to address three issues that have received much attention in Federal and State policy arenas: 

extended work hours and fatigue, mandatory overtime, and regulation of nurse staffing levels. 

The report produced by the IOM in response to this charge, Keeping Patients Safe: 

Transforming the Work Environment of Nurses,

 6 is significant for three reasons: 

1. It documents the key role that nurses (the largest component of the health care 

workforce) play in patient safety and makes specific recommendations for changing their 

work environments to improve patient safety. 

2. It highlights the role that an organization’s governing boards, executive leadership, other 

management personnel, and practices play in patient safety by shaping organizational 

work environments. 

3. It identifies generic workplace processes and characteristics that threaten or protect 

patient safety, not just with respect to nurses’ actions, but by affecting the actions of all 

health care practitioners. 

Keeping Patients Safe’s recommendations are addressed to those parties that most directly 

shape work environments: health care organizations, Federal and State regulators, labor 

organizations, as well as other leaders in health care and nursing education. (The 

recommendations are reproduced in the section below, “Recommendations for Promoting Patient 

Safety in the Work Environments of Nurses.”) However, individual nurses can also use the 

recommendations of this report to improve work environments in ways that keep patients safe 

from errors in their health care. The evidence presented in Keeping Patients Safe identifies 

factors that all nurses should take into consideration in selecting the health care organization in 

which to be employed, in participating in labor-management discussions, and in interacting in 

their employing organizations’ efforts to reduce health care errors. 

Practice Implications 

Keeping Patients Safe identifies eight overarching safeguards to protect patient safety that 

need to be in place within all health care organizations in which nurses work: (1) organizational 

governing boards that focus on safety; (2) the practice of evidence-based management and 

leadership; (3) effective nursing leadership; (4) adequate staffing; (5) provision of ongoing 

2 
Practice Implications of Keeping Patients Safe

learning and clinical decisionmaking support to nursing staff; (6) mechanisms that promote 

interdisciplinary collaboration; (7) work design practices that defend against fatigue and unsafe 

work; and (8) a fair and just error reporting, analysis, and feedback system with training and 

rewards for patient safety (see Table 1). 

Table 1. Necessary Patient Safeguards in the Work Environment of Nurses

Governing Boards That Focus on Safety 

• Are knowledgeable about the link between management practices and patient safety. 

• Emphasize patient safety to the same extent as financial and productivity goals. 

Leadership and Evidence-Based Management Structures and Processes 

• Provide ongoing vigilance in balancing efficiency and patient safety. 

• Demonstrate and promote trust in and by nursing staff. 

• Actively manage the process of change. 

• Engage nursing staff in nonhierarchical decisionmaking and work design. 

• Establish the organization as a “learning organization.” 

Effective Nursing Leadership 

• Participates in executive decisionmaking. 

• Represents nursing staff to management. 

• Achieves effective communication between nurses and other clinical leadership. 

• Facilitates input from direct-care nursing staff into decisionmaking. 

• Commands organizational resources for nursing knowledge acquisition and clinical decisionmaking. 

Adequate Staffing 

• Is established by sound methodologies as determined by nursing staff. 

• Provides mechanisms to accommodate unplanned variations in patient care workload. 

• Enables nursing staff to regulate nursing unit workflow. 

• Is consistent with best available evidence on safe staffing thresholds. 

Organizational Support for Ongoing Learning and Decision Support 

• Uses preceptors for novice nurses. 

• Provides ongoing educational support and resources to nursing staff. 

• Provides training in new technology. 

• Provides decision support at the point of care. 

Mechanisms That Promote Interdisciplinary Collaboration 

• Use interdisciplinary practice mechanisms, such as interdisciplinary patient care rounds. 

• Provide formal education and training in interdisciplinary collaboration for all health care providers. 

Work Design That Promotes Safety 

• Defends against fatigue and unsafe and inefficient work design. 

• Tackles medication administration, handwashing, documentation, and other high-priority practices. 

Organizational Culture That Continuously Strengthens Patient Safety 

• Regularly reviews organizational success in achieving formally specified safety objectives. 

• Fosters a fair and just error-reporting, analysis, and feedback system. 

• Trains and rewards workers for safety. 

Source: Committee on the Work Environment for Nurses and Patient Safety, 20046

: pages 16-17. Reprinted with Permission.

©2004 National Academy of Sciences.

Keeping Patients Safe’s 18 recommendations describe actions health care organizations, 

governmental policymakers, labor organizations, and other leaders in health care and nursing 

should take to promote patient safety in nurse work environments. While not directed principally 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

to individual nurses in clinical practice, the recommendations also can be used by nurses to 

leverage improvements in patient safety. Specifically, the recommendations have corollary 

questions (presented in Table 2) that nurses should ask of prospective and current employers. 

Table 2. Questions Nurses Should Ask Prospective (and Current) Employers About Patient Safety 

Governing Boards That Focus on Safety 

1. What are the organization’s most recent statistics on patient care errors, near misses, and adverse 

events? 

2. How long has the organization been measuring these, and what do the trends show? 

3. What activities does the organization have underway to improve patient safety, and what are the 

quantitative results of these initiatives to date? 

4. Does the governing board review results of measurement of patient safety? How frequently? 

 

Evidence-Based Management Structures and Processes 

5. What mechanisms does the organization have in place to enable it to function as a “learning 

organization,” i.e., to internally create and acquire from external sources new knowledge of better health 

care practices, distribute this knowledge throughout the organization, and change its policies and 

practices to reflect this new knowledge? 

Effective Nursing Leadership 

6. What person in the organization represents clinical nursing staff to the organization’s governing board and 

management? What percent of this person’s time is dedicated to improving clinical nursing care? Is this 

person a nurse? Of what senior management structures is this person a part? 

7. How much funding and other organizational resources does nursing leadership have in its budget to 

support nurses’ acquisition of knowledge? 

8. To what nursing manager will the position in question report? What are the responsibilities of this nurse 

manager, and what portion of the nurse manager’s time is generally spent in each of these 

responsibilities? What proportion of the nurse manager’s time is spent providing supervisory and 

managerial support to clinical staff? How much time does the nurse manager spend providing direct 

patient care to his or her assigned caseload? 

Adequate Staffing 

9. What methods does the organization use to determine safe nurse staffing levels? Can you get a copy of 

the methodology? 

10. What input do clinical nurse staff have in reviewing and modifying the staffing methodology? How 

frequently are the methodology and its assumptions reviewed? 

11. Does the organization count admissions, discharges, and “less than full-day” patients (in 

addition to a census of patients at a point in time) in its estimates of patient volume for 

projecting staffing needs? 

12. What mechanisms does the organization use to quickly secure additional staffing when need for nurse 

staffing is higher than anticipated—e.g., an internal float pool, use of staff from external agencies, staffing 

at higher levels to provide “slack” in the system, other mechanisms? Does the organization avoid use of 

nurses from external agencies? 

13. What roles does clinical nursing staff have in determining admissions and discharges to the unit? 

14. What is the nurse turnover rate for the organization? How is this calculated? 

15. If an acute care hospital, what are the nurse-patient staffing levels in the intensive care units (ICUs)? 

16. If a long-term care facility, is there at least one RN in the facility around the clock, seven days a week? 

Organizational Support for Ongoing Learning and Decision Support 

17. How does the organization support new graduate nurses and nurses new to the organization? Does it 

assign preceptors? How long is orientation? 

18. What percent of the organization’s nursing payroll is dedicated to the ongoing acquisition and 

maintenance of knowledge of the nursing staff? 

19. To what extent does the organization annually ensure that each licensed nurse and nurse 

assistant has an individualized plan and resources for their educational development?

20. What types of decision support technology does the organization provide to nursing staff? 

21. Does the organization use an electronic health record (EHR)? Does the EHR include decision support? 

4 
Practice Implications of Keeping Patients Safe

Mechanisms That Promote Interdisciplinary Collaboration 

22. What mechanisms (such as interdisciplinary patient care rounds) does the organization have in place to 

promote interdisciplinary collaboration? 

23. Does the organization provide formal education and training in interdisciplinary collaboration for all health 

care providers? 

Work Design That Promotes Safety 

24. What are the organization’s policies with respect to nursing work hours? Do they prevent 

direct-care nurses from working longer than 12 hours in a 24-hour period and in excess of 60 

hours per 7-day period under both voluntary and mandatory work hours? 

25. Has the organization undertaken initiatives to design or redesign the work environment and care 

processes to reduce errors? What care processes did these initiatives address? Did the design 

of these efforts directly involve direct-care nurses? 

26. Has the organization undertaken initiatives to improve hand washing and the safety of 

medication administration? When were they conducted and what were the results? 

Organizational Culture That Continuously Strengthens Patient Safety 

27. What are the organization‘s short- and long-term safety objectives? 

28. How and how frequently does the organization review its success in meeting these? 

29. What are the organization’s policies and procedures for reporting errors, near misses, and 

adverse events in care? 

30. Does the organization assure a de-identified, fair, and just reporting system for errors and near 

misses? How does it do this? 

31. What are the organization’s procedures for analyzing errors and providing feedback to directcare workers? 

32. Does the organization conduct an annual, confidential survey of nursing and other health care 

workers to assess the extent to which a culture of safety exists? 

33. To what extent does the organization provide employee training in error detection, analysis, 

and reduction? 

34. What rewards and incentives does the organization use to reduce health care errors? 

Recommendations for Promoting Patient Safety in the 

Work Environments of Nursesb

Recommendations for Transformational Leadership and EvidenceBased Management 

Creating work environments for nurses that are most conducive to patient safety will require 

fundamental changes throughout many health care organizations (HCOs) in terms of how work 

is designed, how personnel are deployed, and how the very culture of the organization 

understands and acts on the science of safety. These changes require leadership capable of 

transforming not just physical environments, but also the beliefs and practices of both nurses and 

other health care workers providing patient care and those in the HCO who establish the policies 

and practices that shape those environments—the individuals who constitute the management of 

the organization. 

 

b

 Reprinted, with permission, from Keeping Patients Safe: Transforming the Work Environment of Nurses.6 ©2004 

National Academy of Sciences. 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Leadership will need to assure the effective use of practices that (1) balance the tension 

between production efficiency and reliability (safety), (2) create and sustain trust throughout the 

organization, (3) actively manage the process of change, (4) involve workers in decisionmaking 

pertaining to work design and work flow, and (5) use knowledge management practices to 

establish the organization as a “learning organization.” To this end, the committee makes the 

following recommendations:

Recommendation 4-1.

c

 HCOs should acquire nurse leaders for all levels of management 

(e.g., at the organization-wide and patient care unit levels) who will: 

• Participate in executive decisions within the HCO. 

• Represent nursing staff to organization management and facilitate their mutual trust. 

• Achieve effective communication between nursing and other clinical leadership. 

• Facilitate input of direct-care nursing staff into operational decisionmaking and the 

design of work processes and work flow. 

• Be provided with organizational resources to support the acquisition, management, 

and dissemination to nursing staff of the knowledge needed to support their clinical 

decisionmaking and actions. 

Recommendation 4-2. Leaders of HCOs should take action to identify and minimize the 

potential adverse effects of their decisions on patient safety by: 

• Educating board members and senior, midlevel, and line managers about the link 

between management practices and safety. 

• Emphasizing safety to the same extent as productivity and financial goals in internal 

management planning and reports and in public reports to stakeholders. 

Recommendation 4-3. HCOs should employ management structures and processes 

throughout the organization that: 

• Provide ongoing vigilance in balancing efficiency and safety. 

• Demonstrate trust in workers and promote trust by workers. 

• Actively manage the process of change. 

• Engage workers in nonhierarchical decisionmaking and in the design of work 

processes and work flow. 

• Establish the organization as a “learning organization.” 

Because HCOs vary in the extent to which they currently employ the above practices and in 

their available resources, the committee also makes the following recommendation: 

Recommendation 4-4. Professional associations, philanthropic organizations, and other 

organizational leaders within the health care industry should sponsor collaboratives that 

incorporate multiple academic and other research-based organizations to support HCOs 

in the identification and adoption of evidence-based management practices. 

Maximizing Workforce Capability 

Monitoring patient health status, performing therapeutic treatments, and integrating patient 

care to avoid health care gaps are nursing functions that directly affect patient safety. 

Accomplishing these activities requires an adequate number of nursing staff with the clinical 

 

c

 For ease of reference, the committee’s recommendations are numbered according to the chapter of the main text in 

which they appear. 

6 
Practice Implications of Keeping Patients Safe

knowledge and skills needed to carry out these interventions and the ability to effectively 

communicate findings and coordinate care with the interventions of other members of the 

patient’s health care team. Nurse staffing levels, the knowledge and skill level of nursing staff, 

and the extent to which workers collaborate in sharing their knowledge and skills all affect 

patient outcomes and safety. 

Regulatory, internal HCO, and marketplace (consumer-driven) approaches are traditionally 

advocated as methods to achieve appropriate staffing levels. The committee determined that each 

of these approaches has limitations as well as strengths; their coordinated and combined use 

holds the most promise for achieving safe staffing levels. The committee also took particular 

note of the need for more accurate and reliable staffing data for hospitals and nursing homes to 

help make these efforts more effective and to facilitate additional needed research on staffing. 

Finally, the committee identified a need for more research on hospital staffing for specific types 

of patient care units, such as medical-surgical and labor and delivery units. The committee 

therefore makes the following recommendations: 

Recommendation 5-1. The U.S. Department of Health and Human Services (DHHS) 

should update existing regulations established in 1990 that specify minimum standards 

for registered and licensed nurse staffing in nursing homes. Updated minimum standards 

should: 

• Require the presence of at least one RN within the facility at all times. 

• Specify staffing levels that increase as the number of patients increase, and that are 

based on the findings and recommendations of the DHHS report to Congress, 

Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes – Phase II 

Final Report.

7

• Address staffing levels for nurse assistants, who provide the majority of patient care. 

Recommendation 5-2. Hospitals and nursing homes should employ nurse staffing 

practices that identify needed nurse staffing for each patient care unit per shift. These 

practices should: 

• Incorporate estimates of patient volume that count admissions, discharges, and “less 

than full-day” patients in addition to a census of patients at a point in time. 

• Involve direct-care nursing staff in determining and evaluating the approaches used to 

determine appropriate unit staffing levels for each shift. 

• Provide for staffing “elasticity” or “slack” within each shift’s scheduling to 

accommodate unpredicted variations in patient volume and acuity and resulting 

workload. Methods used to provide slack should give preference to scheduling excess 

staff and creating cross-trained float pools within the HCO. Use of nurses from 

external agencies should be avoided. 

• Empower nursing unit staff to regulate unit work flow and set criteria for unit 

closures to new admissions and transfers as nursing workload and staffing necessitate. 

• Involve direct-care nursing staff in identifying the causes of nursing staff turnover 

and in developing methods to improve nursing staff retention. 

Recommendation 5-3. Hospitals and nursing homes should perform ongoing evaluation 

of the effectiveness of their nurse staffing practices with respect to patient safety, and 

increase internal oversight of their staffing methods, levels, and effects on patient safety 

whenever staffing falls below the following levels for a 24-hour day: 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• In hospital ICUs—one licensed nurse for every two patients (12 hours of licensed 

nursing staff per patient day). 

• In nursing homes, for long-stay residents—one RN for every 32 patients (.75 hours 

per resident day), one licensed nurse for every 18 patients (1.3 hours per resident 

day), and one nurse assistant for every 8.5 patients (2.8 hours per resident day). 

Recommendation 5-4. DHHS should implement a nationwide, publicly accessible 

system for collecting and managing valid and reliable staffing and turnover data from 

hospitals and nursing homes. Information on individual hospital and nursing home 

staffing at the level of individual nursing units and the facility in the aggregate should be 

disclosed routinely to the public. 

• Federal and State nursing home report cards should include standardized, case-mix–

adjusted information on the average hours per patient day of RN, licensed, and nurse 

assistant care provided to residents and a comparison with Federal and State 

standards. 

• During the next 3 years, public and private sponsors of the new hospital report card to 

be located on the Federal government website should undertake an initiative—in 

collaboration with experts in acute hospital care, nurse staffing, and consumer 

information—to develop, test, and implement measures of hospital nurse staffing 

levels for the public. 

Moreover, the knowledge base on effective clinical care and new health care technologies is 

increasing rapidly, making it impossible for nurses (and other clinicians) to incorporate this 

information into their clinical decisionmaking and practice without organizational support. 

Organizational studies and research on exemplary work environments indicate the importance of 

investment in ongoing employee learning by employers. The committee therefore makes the 

following recommendation: 

Recommendation 5-5. HCOs should dedicate budgetary resources equal to a defined 

percentage of nursing payroll to support nursing staff in their ongoing acquisition and 

maintenance of knowledge and skills. These resources should be sufficient for and used 

to implement policies and practices that: 

• Assign experienced nursing staff to precept nurses newly practicing in a clinical area 

to address knowledge and skill gaps. 

• Annually ensure that each licensed nurse and nurse assistant has an individualized 

plan and resources for educational development within health care. 

• Provide education and training of staff as new technology or changes in the 

workplace are introduced. 

• Provide decision support technology identified with the active involvement of directcare nursing staff to enable point-of-care learning. 

• Disseminate to individual staff organizational learning as captured in clinical tools, 

algorithms, and pathways. 

Finally, in response to evidence on inconsistent interprofessional collaboration among 

nursing staff and other health care providers, the committee makes the following 

recommendation: 

Recommendation 5-6. HCOs should take action to support interdisciplinary 

collaboration by adopting such interdisciplinary practice mechanisms as interdisciplinary 

rounds, and by providing ongoing formal education and training in interdisciplinary 

8 
Practice Implications of Keeping Patients Safe

collaboration for all health care providers on a regularly scheduled, continuous basis 

(e.g., monthly, quarterly, or semiannually). 

Design of Work and Workspace To Prevent and Mitigate Errors 

Nurses’ work processes and workspaces need to be designed to make them more efficient, 

less conducive to the commission of errors, and more amenable to detecting and remedying 

errors when they occur. The work hours of a minority of nurses, in particular, are identified as a 

serious threat to the safety of patients. The effects of fatigue include slowed reaction time, lapses 

of attention to detail, errors of omission, compromised problem solving, reduced motivation, and 

decreased energy for successful completion of required tasks. Other safety-sensitive industries 

have acknowledged and taken action to defend against these effects by limiting the number of 

shifts or hours worked in a week. 

Changing work patterns will require attention from HCOs, regulatory bodies, State boards of 

nursing, schools of nursing, and nurses themselves. Accordingly, the committee makes the 

following recommendation: 

Recommendation 6-1. To reduce error-producing fatigue, State regulatory bodies should 

prohibit nursing staff from providing patient care in any combination of scheduled shifts, 

mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour 

period and in excess of 60 hours per 7-day period. To this end: 

• HCOs and labor organizations representing nursing staff should establish policies and 

practices designed to prevent nurses who provide direct patient care from working 

longer than 12 hours in a 24-hour period and in excess of 60 hours per 7-day period. 

• Schools of nursing, State boards of nursing, and HCOs should educate nurses about 

the threats to patient safety caused by fatigue. 

Enabling nursing staff to collaborate with other health care personnel in identifying high-risk 

and inefficient work processes and workspaces and (re)designing them for patient safety and 

efficiency is also essential. Moreover, documentation practices are in great need of redesign. 

However, this cannot be accomplished solely by nursing staff and internal HCO efforts. As many 

documentation practices are driven by external parties, such as regulators and oversight 

organizations, these entities will need to assist in the redesign of documentation practices. To 

address these needs, the committee makes the following recommendations: 

Recommendation 6-2. HCOs should provide nursing leadership with resources that 

enable them to design the nursing work environment and care processes to reduce errors. 

These efforts must directly involve direct-care nurses throughout all phases of the work 

design and should concentrate on errors associated with: 

• Surveillance of patient health status. 

• Patient transfers and other patient hand-offs. 

• Complex patient care processes. 

• Non–value-added activities performed by nurses, such as locating and obtaining 

supplies, looking for personnel, completing redundant and unnecessary 

documentation, and compensating for poor communication systems. 

Recommendation 6-3. HCOs should address handwashing and medication 

administration among their first work design initiatives. 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Recommendation 6-4. Regulators, leaders in health care; and experts in nursing, law, 

informatics, and related disciplines should jointly convene to identify strategies for safely 

reducing the burden associated with patient and work-related documentation. 

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 safeguard 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 organizations place as high a priority on 

safety as they do on production; all employees are fully engaged in the process of detecting highrisk situations before an error occurs. Management is so responsive to employees’ detection 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 pervasive and observable in the behaviors of these organizations and their employees 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 commitment 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 priority, with every 

organizational member understanding that each is fallible, even with the best of intentions, as are 

the processes used. Moreover, establishing a fair and just culture in responding to errors reduces 

workers’ fear and disincentives to report errors and near misses. As a result, nursing staff is 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 Congress 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 leadership, and labor 

partners should create and sustain cultures of safety by implementing the 

recommendations presented previously and by: 

• Specifying short- and long-term safety objectives. 

• Continuously reviewing success in meeting these objectives and providing feedback 

at all levels. 

• Conducting an annual, confidential survey of nursing and other health care workers to 

assess the extent to which a culture of safety exists. 

• Instituting a de-identified, fair, and just reporting system for errors and near misses. 

• Engaging in ongoing employee training in error detection, analysis, and reduction. 

10 
Practice Implications of Keeping Patients Safe

• Implementing procedures for analyzing errors and providing feedback to direct-care 

workers. 

• Instituting rewards and incentives for error reduction. 

Recommendation 7-2. The National Council of State Boards of Nursing, in consultation 

with patient safety experts and health care leaders, should undertake an initiative to 

design uniform processes across States for better distinguishing human errors from 

willful negligence and intentional misconduct, along with guidelines for their application 

by State boards of nursing and other State regulatory bodies having authority over nursing. 

Recommendation 7-3. Congress should pass legislation to extend peer review 

protections to data related to patient safety and quality improvement that are collected 

and analyzed by HCOs for internal use or shared with others solely for purposes of 

improving safety and quality. 

Research Implications 

Finally, the committee notes that changing health care delivery practices to increase patient 

safety must be an ongoing process. Research findings and dissemination of practices that other 

HCOs have found successful in improving patient safety will help HCOs as learning 

organizations add to their repertoire of patient safety practices. This report calls attention to 

several areas in which, at present, information is limited about how to design nurses’ work and 

work environments to make them safer for patients. Research is needed to provide better 

information on nursing-related errors, means of achieving safer work processes and workspace 

design, a standardized approach to measuring patient acuity, information on safe staffing levels 

for different types of patient care units, effective methods to help night shift workers compensate 

for fatigue, information on what limits should be imposed on successive days of working 

sustained work hours, and collaborative models of care. Accordingly, the committee makes the 

following recommendation: 

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 

d teams.

 

d

 This is the end of the copyrighted material reproduced, with permission, from the IOM report Keeping Patients Safe. 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Conclusion 

Nurses are in a key position to improve patient safety, not just through their individual 

patient care actions as clinicians, but by exercising their leverage as much-desired employees in 

the labor marketplace. If nurses ask the above questions of their prospective employers, and 

incorporate the responses they receive into their selection of their place of employment, they will 

be able to exert significant influence within the health care system, as health care organizations 

come to appreciate the ability to recruit nurses as an additional important reason for making the 

types of organizational changes needed to provide safe patient care. 

Author Affiliation 

Ann E. K. Page, R.N., M.P.H., senior program officer, Institute of Medicine. E-mail: 

aekpage@NAS.edu. 

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