Such a center would provide a focal point for safety and quality activities by focusing on safety issues applicable to the full range of providers and health delivery systems. This entity must include adequate representation by nurses and other health professionals who are the front-line individuals in patient care. This Center must support research to determine what factors lead to errors. Specifically, the Center must be charged with collecting data on organizational practices and other factors that may be associated with the occurrence of errors. In our current knowledge, no one can state with any certainty what practices could or are more likely to lead to errors.
Some practices are more obvious than others.
For example, bad handwriting or open stock of certain powerful drugs have been observed to be the cause for errors in health care delivery. Other causal factors that may contribute to health care errors may not be as apparent. For example, the IOM report lacks important information on the relationship between system errors and appropriate nurse staffing. In fact, ANA has voiced criticism of the report due to its inadequate attention to the staffing component of this issue. Inadequate or inappropriate staffing may mean too few registered nurses, lack of appropriate training or orientation for an RN assigned to the unit or inappropriate use of unlicensed personnel.