The Unfinished Patient Safety Agenda
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital CEOs listed patient safety among their top three concerns in 2004—no significant change over previous years.(1)
The IOM report on medical errors certainly heightened awareness about patient safety and stimulated considerable activity. Congress increased funding for patient safety research, and, although the initial funding levels were not sustained, new and useful information is emerging. The National Quality Forum developed quality indictors that, if implemented in hospitals nationally, could help improve safety and quality. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) now generates patient safety requirements, updated yearly, for its more than 15,000 accredited and certified health care organizations and programs. The Leapfrog Group, an organization representing the interests of health care purchasers, has aggressively promoted three initiatives that are estimated to potentially avert some 60,000 deaths and hundreds of thousands of medication errors a year: computerized physician order entry (CPOE), referrals to high-volume hospitals for high-risk surgery and neonatal intensive care, and ICU physician staffing by trained intensivists. More than 2000 hospitals are participating in the Institute for Healthcare Improvement's (IHI) campaign to save 100,000 lives a year by implementing six care improvements, including the deployment of rapid response teams and the use of evidence-based strategies to prevent ventilator-associated pneumonia.
Impressive as these activities are, there is a striking omission: there is little, if any, emphasis on reversing what doctors, nurses, and patients all agree is inadequate nurse staffing in hospitals, and little focus on fundamental reforms of unsafe and inefficient nurse practice environments.
A strong evidence base suggests that focusing on nursing would improve patient safety. Nurses comprise the surveillance system in hospitals for errors and adverse occurrences. If the nurse surveillance system worked better, there might be less need for the deployment of rapid response teams, intensivists in ICUs, and other initiatives currently receiving great attention. The effectiveness of nurse surveillance is influenced by nurse staffing ratios, nurses' educational qualifications, and the quality of the work environment, all of which vary significantly across hospitals. Hospitals in which nurses, on average, care for eight patients each have risk-adjusted mortality rates following common inpatient surgical procedures that are 31% higher than hospitals in which nurses care for four patients each, after controlling for relevant hospital characteristics such as size, teaching status, and technology.(2) Similar differences in failure to rescue rates were documented. Staffing hospitals uniformly at four versus eight patients per nurse would be expected to prevent 5 deaths per 1000 patients.(2) Additionally, every 10% increase in the proportion of a hospital's staff nurse workforce with a baccalaureate degree or even higher levels of education is associated with a 5% decline in mortality (3), and hospitals with better nurse work environments have fewer adverse patient outcomes than hospitals with poorer work environments.(4)
Approximately 4 million common surgical procedures of the type we studied (3,4) are undertaken each year. Therefore, our findings suggest that 20,000 lives could be saved by improved nurse staffing for patients undergoing common inpatient surgical procedures. Moreover, given approximately 35 million hospital admissions a year, well over 50,000 lives a year could potentially be saved through investments in nursing. Thus, the evidence suggests that improved nurse staffing, investments in enhancing nurses' education, and improvements in the nurse practice environment have the potential to yield benefits to patients as great as or greater than other initiatives that have garnered top billing to date in the national effort to make medical care safer. As one example, the evidence linking nurse staffing to patient outcomes is considerably more extensive than more recent research on physician intensivists.
Why hasn't nursing, and particularly nurse staffing, received more attention with regard to its potential to improve patient safety? Part of the reason probably relates to leaders' perceptions of an intractable nurse shortage, which has provided justification for looking elsewhere for safety initiatives. Of course, the high cost presumed to be associated with improving nurse staffing is a major deterrent. Also missing is a credible, independent advocate for investments in nursing as a safety measure.
What actions should be taken? Baccalaureate nursing school student and faculty capacity should be expanded enough to accommodate the estimated 125,000 qualified applicants the National League for Nursing reported were turned away last year from all nursing schools. Efforts to transform care at the bedside, including improved nurse staffing and working conditions, must move beyond small pilot projects. A respected advocacy organization like the Leapfrog Group or the IHI is required to help interpret the significance and applicability of research findings linking more nurses to better patient outcomes, to help overcome the fears of stakeholders that tackling nurse understaffing will sink hospitals financially. Payment reforms must incorporate the reality that decreasing hospital length of stay and technology advancements create ever-increasing registered nurse staffing requirements. Work redesign that provides significantly better support to the clinical nurse function could substantially increase nurse productivity and possibly moderate demand for nurses. The huge amount of time hospital-based registered nurses spent searching for pillows is one of hundreds of examples of inadequate institutional support for nursing care. The Magnet Recognition Program of the American Nurses Credentialing Center is the best example of a successful blueprint to guide culture change in the nurse practice environment. While interest in Magnet Recognition is soaring, many more hospitals could benefit from becoming engaged in the Journey to Nursing Excellence.(5) Legislative mandates specifying minimum nurse staffing ratios have been enacted in California and are under consideration in other states. If mandates can be implemented without major unintended consequences that adversely affect access and other aspects of care, patient safety should be enhanced, although voluntary actions to address the adequacy of nurse staffing would be preferable to most stakeholders.
Linda H. Aiken, PhD, RNDirector, Center for Health Outcomes and Policy Research Claire M. Fagin Leadership Professor of Nursing and Professor of Sociology University of Pennsylvania
1. Top Issues Confronting Hospitals: 2004. American College of Healthcare Executives Web site. Available at: http://www.ache.org/PUBS/research/ceoissues.cfm. Accessed June 29, 2005.
2. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987-1993. [ go to PubMed ]
3. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623. [ go to PubMed ]
4. Aiken LH, Clarke SP, Sloane DM, for the International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J for Qual Health Care. 2002;14:5-13. [ go to PubMed ]
5. McClure ML, Hinshaw AS, eds. Magnet Hospitals Revisited. Washington DC: American Nurses Association; 2002.