Panel 3: Particular Systems Issues
Testimony of Patricia W. Underwood, American Nurses Association
The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summitís goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs.
Individuals were selected by the Agency for Healthcare Research and Quality (AHRQ) to testify at the summit as members of the witness panels. Each submitted written statements for the record before the event, documenting key issues that they confront with regard to patient safety as well as questions to be researched. Other applicants were invited to submit written statements.
Disclaimer and Copyright Statements
The American Nurses Association (ANA) appreciates the opportunity to address the nursing
profession's perspective on areas for priority consideration in developing a research agenda
related to public safety and medical errors. This issue is one of great importance to the
nursing profession. As front line health care workers, nurses have substantial contributions
to make in the effort to reduce health care errors. ANA is the only full-service professional
organization representing the nation's registered nurses through its 53 state and territorial
nurses associations. Members of ANA constituent associations include staff nurses,
advanced practice nurses, academics, researchers, and nurse administrators. The scope of
ANA's membership, reaching into all varieties of nursing experience in every type of practice
setting, gives ANA the capacity to address issues of error and public safety in a
We will also address particular staffing issues that impact quality of care and incidence of
medical errors by a broader range of hospital personnel. While the nursing profession
cannot appropriately speak to the specific concerns of other disciplines and auxiliary
personnel, as the primary coordinators of care in institutions, nursing has insights that should
valuable in all facets of the discussion of staffing and medical error.
The recent Institute of Medicine (IOM) study, To Err Is Human: Building a Safer Health
System (IOM, December 1999), quantified what nurses and other health
professionals have been concerned about for quite some time: changes in the health care
system have compromised the safety and quality of care and have contributed to the
unacceptable and alarming incidence of medical errors. The IOM study identified many
factors that contribute to medical errors and compromise public safety. However, the report
failed to consider a significant structural component of health care delivery: the number and
mix of health care staff delivering direct patient care. Over the past ten years, many expert
and seasoned registered nurses (RNs) at all levels in health care institutions, have left or
been forced to leave the delivery of direct patient care, especially within the acute care
system. In many instances they have been replaced by unlicensed assistive personnel. It is
the experience of many remaining RNs that their ability to influence the design of care
delivery systems and to advocate effectively for patient safety has been diminished as
institutions have increasingly focused on cost containment as a priority.
An important consideration in the discussion of medical errors, particularly in institutional
settings, is to keep in mind that patients are in health care facilities for expert nursing care.
Patients who have been treated or have undergone a medical procedure and then do not
need expert nursing care are sent home. Therefore, any consideration of medical errors that
does not look at a full range of nurse staffing issues is missing a crucial element that lies at
the center of safe patient care. The fact that the IOM report had essentially nothing to say
about this issue and the paucity of research in this area are both indicative of the relative neglect of
staffing research. The American Nurses Association has pushed hard for a number of years
to remedy this neglect.
ANA is very much encouraged by a 1998 study by researchers for the Agency for Health
Care Policy and Research (AHCPR), now the Agency for Health Research and Quality,
examining the relationship between nurse staffing and selected adverse events. The study,
"Nurse staffing levels and adverse events following surgery in U. S. hospitals" (Kovner and
showed that patients who have surgery done in hospitals that have fewer registered nurses
per patient than other hospitals run a higher risk of developing avoidable complications
following their operations. The study found hospitals that provided one more hour of nursing
care per patient day than the average nursing care hours per patient day had almost ten
percent fewer patients with urinary tract infections and 8 percent fewer patients with
pneumonia. An additional one hour per day of nursing care is about a seventeen percent
increase in nurse staffing levels.
Researchers Christine Kovner, Ph.D., R.N., and Peter Gergen, M.D., M.P.H., in analyzing data
from 506 hospitals in ten states, found that the fewer full-time equivalent registered nurses
per inpatient day a hospital has, the greater the incidence of urinary tract infection, pneumonia, thrombosis (formation of blood clots),
pulmonary congestion, and other lung-related problems following major surgery. These are
complications that nurses often can prevent by getting patients out of bed and walking after
surgery, by monitoring them closely, and by other hands-on nursing practices.
According to Kovner, in a report by AHCPR, the finding of a strong inverse relationship
between registered nurse staffing and adverse patient events should be considered when
developing strategies to reduce costs. About 1.2 million registered nurses work in hospitals,
where they make up nearly a quarter of hospital staff and constitute hospitals' single largest
Among the study's other findings are that large hospitals have significantly lower urinary tract
infection rates than smaller ones; large and medium-sized hospitals have higher rates of
lung-related disorders than smaller facilities; and both public and not-for-profit hospitals have
significantly lower urinary tract infection rates than do for-profit hospitals. This study
reinforces previous studies, limited both in numbers and in scope and design, showing a
significant correlation between registered nurse staff and the quality of care in health care
The vital importance of registered nurses at the bedside is a critical piece in preventing medication errors. The registered nurse at the patient's bedside is the patient's
safety net. ANA agrees with the IOM study's recommendation that health care organizations
should implement proven medication safety procedures. However, an area of inadequate
staffing that needs to be addressed is the inappropriate use of unlicensed assistive
personnel (UAP). The role of the UAP is important. The UAP is to provide assistance to the
registered nurse, not substituting for the RN by delivering care that is within an RN's scope of
practice. While some procedural components of nursing care can be performed by
unlicensed persons, the assessment and critical judgment components that are essential to
quality of care are lost. More health care facilities, especially state facilities, are increasingly
relying on UAPs to administer medications. Thus, medication administration occurs without
the application of critical judgment.
The organization of health care within a hospital depends on interdisciplinary teams of
professionals and auxiliary workers, all of whom have defined areas of expertise and
responsibility. Provision of safe care demands that there be adequate numbers of each of
these health care team members and that their deployment be appropriate to their training
and expertise. One of the reasons that proposals to require specific ratios of specific types
of practitioner are problematic is that they do not ensure that a full complement staff are
available. For instance, if a certain number of registered nurses is required for a particular patient census and acuity, it is counterproductive to then permit a reduction in
numbers of respiratory therapists or unlicensed assistants as a cost saving measure.
Currently a number of states have legalized medication administration by unlicensed
personnel in state institutions and subacute care facilities. For example, the Commonwealth
of Massachusetts General Law Chapter 94C,7g authorizes unlicensed personnel to
administer medication to patients within the Departments of Mental Retardation and Mental
Health. The oversight of a registered nurses is not mandated by the state. The
Massachusetts Nurses Association has been battling with the Massachusetts state
legislature for many years regarding this issue. Financial cost appears to be the reason the
Commonwealth does not raise the standard of care for their most vulnerable patients.
Massachusetts is not the only state that relies on UAPs to administer medications; New
York, Maine, Illinois, and others have similar laws. ANA recommends review of the
inappropriate use of UAPs administering medications in each state. Another area in which
the administration of medication by unlicensed individuals is increasing is in schools. In
1996, there were approximately 45,000 school nurses, mostly part-time, for 87,125 school
buildings and millions of school children. Because of the low number of school nurses
working in the school systems, many students received their medication from school
administrators. This trend is particularly worrisome because many children with disabilities, who are being accommodated in the public school systems, may
have complex medication and therapeutic needs. It is unsafe for these children and unfair to
the administrative personnel and teachers who are being required to perform nursing duties
to permit these practices to continue.
For a number of years, ANA has advocated for enactment of legislation to require health
care institutions to make public specified information on staffing levels, mix and patient
outcomes. At a minimum, institutions would have to make public, in comparable formats:
- the number of registered nurses providing direct care;
- numbers of unlicensed personnel utilized to provide direct patient care;
- average number of patients per registered nurse providing direct patient care;
- patient mortality rate;
- incidence of adverse patient care incidents;
- methods used for determining and adjusting staffing levels and patient care needs.
The reason for this legislative proposal goes to the heart of the problem: transparency in
health care quality and safety is more important than commercial proprietary considerations
of health care institutions. If researchers do not have access to the dataand data that is in usable formthen every claim by the nursing
profession of the effects of understaffing or inappropriate staffing on patient safety can be
dismissed as unsupported. But to go further, if there is no funding for the research, we are
left in the same untenable position and patients continue to pay the price with their health
and safety on the line. For the nursing profession, the indictment of "anecdotal claims," as
opposed to scientific evidence, is extraordinarily frustrating. The profession is committed to
evidence-based decisionmaking and care. The proprietary control of the data and the level
of funding necessary for research of this nature are typically not available to nurse
researchers. These barriers are longstanding and must be overcome if public health and
safety interests are to be served.
That concern about necessary research brings us to ANA's proposals for addressing a
systemic medical error problem. ANA believes that staffing (the number and mix of hospital
and other institutional staff) is the most significant aspect of the health care delivery
infrastructure and requires specific focus by the research community. The following areas
are proposed for consideration:
I. Research is needed to evaluate the occurrence of medical errors in relationship to
the following variables:
- Average ratio of patients to registered nurses, to licensed practical nurses, and to
- Differential illness severity;
- Mortality and morbidity rates;
- Incidence of post-discharge professional care;
- Length of stay.
Obviously, these relationships are complex, and they both illustrate and intensify the
complexities of the changing modern health care system. When determining the appropriate
staff mix for hours of care, one size (or formula) does not fit all. In fact, staffing is most
appropriate and meaningful when it is based on a measure of unit intensity which takes into
consideration the aggregate population of patients and the associated roles and
responsibilities of staff. Such a unit of measure must be operationalized taking into
consideration all of the patients for whom care is being provided. It must not be based on a
simple quantification of the needs of "average" patients but must also include the "outliers."
Inadequate or inappropriate staffing may mean too few registered nurses, lack of appropriate
training or orientation for a registered nurse assigned to the unit, or inappropriate use of
unlicensed personnel. Adequate numbers of staff are necessary to reach a safe level of
patient care services. Ongoing evaluation and bench marking related to staffing and patient
acuity are necessary elements in the provision of quality care.
It is not a simple matter to tease out the significance of these variables. But if it is not done,
there will continue to be a serious deficiency in the information necessary to make staffing
decisions that are efficient and, more importantly, that will ensure maximum patient safety.
In this era of shortened hospital stays and of outpatient surgery, assigning only one or two
registered nurses to an intensive care unit with twelve patients sends off alarm signals for
any reasonably informed lay person. Yet registered nurses know, and sometimes complain
at the risk of their jobs, that this circumstance is not unusual. Are mistakes more likely then?
A "stands-to-reason" argument will not do. It is essential to have valid and reliable data
collection and analysis, because nurses' anecdotal experiences are repeatedly dismissed or
downplayed by administrators and policymakers.
II. Examine the relationship between error rates and continuous hours worked by
health care professionals and other health care workers
The American Nurses Association has identified the problem of excessive overtime required
of registered nurses as a public health crisis. The fatigue experienced by other hospital
employees, such as pharmacists, dieticians, respiratory therapists, and others is, in the
same way a contributing factor to the incidence of medical errors.
The medical profession is at long last beginning to address the danger to patients of interns
and residents working for hours and days without proper rest. In contrast, nurses and other
hospital personnel are increasingly being required to work excessive overtime. In today's
health care workplace, sixteen hour shifts for nurses are becoming increasingly
commonplace and it is not unheard of to have twenty-four hour shifts. Too many hospitals
have come to rely on the use of overtime as a substitute for an adequate supply of staff.
Even the benign sounding reference to use of overtime in "emergencies" too often masks an
inappropriate manipulation of staff rather than responsible provision for the usual changes in
patient census or acuity or other routine institutional staffing needs. It is important to note
that the issue of overtime is not focused on true emergencies - natural disasters in which
members of the nursing profession, as well as other emergency workers, have always given help to the very limits of their capacity
to do so.
Consider here the issue of power: relative to the nursing profession, the medical profession
is in a stronger position to influence practice conditions, at least in part because they are
reimbursed for services independently. Nurses and other employees of the institutions
traditionally do not hold the power to dominate, much less control, resource decisions,
because they are regarded as a labor cost center rather than revenue producers. In this
environment, staffing decisions are disproportionately affected by the bottom-line mentality
that controls the health care industry.
III. Evaluate the relationship between work environment (quality of work life) and
patient safety by assessing the trends in work-related staff illness and injury rates;
turnover/vacancy rates; overtime rates; use of supplemental staffing; levels of staff
satisfaction; flexibility of human resource policies and benefits packages; and
compliance with applicable federal state and local regulations.
Health care delivery inherently involves a certain level of stress which can be physically and
emotionally exhausting. Those conditions can be exacerbated by the work environment. Again, it is not only possible, but probable, that these conditions
and stresses may contribute to medical errors and threaten patient safety. ANA
recommends that studies be undertaken which examine the effects of the workplace
environment on the effects on patient safety. A rigorous analysis, unbiased by exigencies of
either the institutions or the workforce, is needed for patient-centered consideration apart
from the usual claims and counterclaims that typically are part of discussions in labor
negotiations. For instance, depending on the setting, nurses and other health care workers
may be at risk for infectious diseases from needlesticks or other sharps injuries, back injuries
from moving patients with inadequate assistance, or violence involving patients or their
family members. These are problems that cause nurses and other health care workers to
leave bedside nursing or other hospital work involving direct patient care, either by choice or
because of disability. More subtle environmental workplace stresses that are imposed by an
employer need to be considered, as well. Rigid personnel policies or unfair scrutiny of
personal behavior contribute to the type of environment that may exacerbate adverse
IV. Research that compares the efficacy in reducing medical errors of institutions that
have enhanced monitoring/reporting systems versus institutions where continuous
quality improvement principles have been implemented as part of the organizations
The principles of continuous quality improvement (CQI) direct the institution's focus away
from an individual incident focus toward examining systems designed to support consistent
outcomes and best practices. The culture of CQI is appropriate to the examination of
medical errors because the majority of medical errors do not result from individual
recklessness, but from basic flaws in the way the health delivery system is organized.
Stocking patient-care units in hospitals, for example, with certain full-strength drugseven
though they are toxic unless dilutedhas resulted in deadly mistakes. Illegible writing in
medical records has resulted in administration of a drug for which the patient has a known
allergy. Our evolving and increasingly complex health care system often lacks adequate
coordination and appropriate systems to ensure patient safety. For example, when a patient
is treated by several practitioners, they often do not have complete information about the
medicines prescribed for each of the patient's diagnoses.
CQI is consistent with a root cause analysis approach that replaces individual blame with
examination of system failures. Research of this nature is often overlooked because it calls
for complex designs that are often of a qualitative rather than a quantitative nature.
Despite increasing evidence that systems fail, institutions are continuing to assign and
emphasize individual blame for errors, misjudgments and patient dissatisfaction. Hospital
systems and administrators are assuming that the appropriate way to deal with the
complexity of errors made in the delivery of health care is to manage the workersthrough
oversight and disciplineas opposed to identifying and resolving the true problem in the
spirit of partnership. ANA has long advocated for investigation of system changes that may
result in egregious errors by individual practitioners, noting that health care systems have
downsized, restructured and reorganized to the point where processes, initially put in place
to protect the public, are breaking down.
As these systems increasingly are failing to protect patients, the severity of discipline applied
to individual providers for mistakes is increasing. For example, in a 1996 Colorado case,
medication errors were not treated as the domain of the hospital and the state licensing
board, but drew the attention of the media and the court systems. Three registered nurses
were charged with criminally negligent homicide when a medication error resulted in the death of a child.
Although criminal prosecution for medication errors is not a common practice, the fact that
such cases exist point to the adherence to promotion of a culture of individual blame. Health
care organizations must approach problem solving strategies through shared accountability
and partnership for quality improvement. A shared accountability approach diminishes focus
on individual blaming and enhances long-range process improvements.
Beyond the institutional attitudes, it is important to consider ways in which day-to-day nursing
practice makes it difficult to strengthen reporting systems. Among nurses, there is typically
an aversion to reporting errors made by other nurses, and there are various reasons within
the culture of the profession and the work environment that could continue to pose barriers
even if a blame-free reporting system is instituted.
For instance, a report of erroneous practice, signed by a nurse, generally entangles that
nurse in the problem; there often is even an assumption that, because her name is one the
report, it is her problem and that she probably caused it. Implications of this sort will not be
dissipated because a new system is in place.
Another, and perhaps more important, aspect of this culture is that nurses, in virtually every
practice environment, rely upon each other to share the work load. In a typical unit, a nurse
who has a patient in crisis needs to have good relationships with her colleagues who will
"cover" her other patients. The personal attributes that are necessary to make this informal
system work militate against anything that smacks of holding a colleague's feet to the fire
outside of the culture itself. This is a complex issue that will not be solved by fiat but by
developing an organizational culture that emphasizes that reported errors are subject to
analysis leading to corrective action and preventive measures rather than punitive action
ANA believes nurses are the quality and safety monitors of health care. Nurses worry about
systems that put providers and patients at risk. Today's environment demands that the
nursing profession assert its powerful voice in the time-honored role as patient advocate by
supporting public policies that protect consumers, enhance accountability for quality, and
promote access to a full range of health care services. However, no system can succeed,
no matter how brilliant, if there aren't qualified staff to implement it. Until health care
administrators and the public focus on reducing system problems that contribute to clinical
errors, shared accountability for systems improvement in health care can not be achieved. It is crucial that substantial resources be committed to documenting
the link between staffing and patient outcomes in order to make informed, data-driven
decisions that will allow safe-quality patient care to be the norm in all patient care settings.
To Err is Human: Building a Safer Health
System. Institute of Medicine. Washington: National Academy Press, 2000.
Kovner, C. and Gergen P. Nurse staffing levels and adverse events following surgery in U. S. hospitals. Image: Journal
of Nursing Scholarship 1998, 30:315-21.
Current as of September 2000
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