The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Zaranko B, Sanford NJ, Kelly E, et al. BMJ Qual Saf. 2023;32:254-263.
Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.
Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.
Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.
Mahat S, Rafferty AM, Vehviläinen-Julkunen K, et al. BMC Health Serv Res. 2022;22:1474.
Healthcare staff who are involved in a medical error often experience emotional distress. Using qualitative methods and text mining of medication error incident reports, researchers in this study identified the negative emotions experienced by healthcare staff after a medication error (e.g., fear, guilt, sadness) and perceptions regarding how superiors and colleagues effectively responded to the events (e.g., reassurance, support, and guidance).
Van Slambrouck L, Verschueren R, Seys D, et al. J Prof Nurs. 2021;37:765-770.
An online survey of nursing students in Belgium found that about one in three students were involved in a patient safety incident during their clinical training, and the majority experienced emotional distress after the event. Medical and nursing curriculum should include opportunities for competency development to support peers involved in patient safety incidents.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77:3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
Peer support programs can help clinicians cope with the emotional consequences of involvement in an adverse event. This cross-sectional survey of Dutch nurses and doctors found that most respondents (86%) had been involved in a patient safety incident at some point during their career but only a small proportion sought out support in the aftermath of the incident.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes.
Brooks Carthon M, Brom H, McHugh MD, et al. Med Care. 2021;59:169-176.
Prior research has shown that lower nurse-to-patient ratios are associated with increased patient mortality. This cross-sectional analysis using multiple data sources from four states assessed the relationship between nurse staffing and survival disparities after in-hospital cardiac arrest. Results indicate that disparities in survival between Black and white patients may be linked to medical-surgical nurse staffing levels, and that the benefit of being treated at a hospital with higher staffing ratios may be especially pronounced for Black patients.
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8:639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.
Härkänen M, Paananen J, Murrells T, et al. BMC Health Serv Res. 2019;19:791.
This retrospective study used text mining to analyze the free text descriptions in 72,390 medication administration incident reports in the National Reporting and Learning System in England and Wales to identify terms most frequently associated with risk that might otherwise remain buried within other non-relevant text. The authors identified the most common medications described in free text (insulin, antibiotics, paracetamol and morphine) and presented the most common free text terms associated with these medications. Results indicate that checking patient allergies and medication doses, especially for intravenous and transdermal medications, should be a focus of efforts to increase medication administration safety.
Clinicians may experience distress after being involved in adverse events. This study of 4369 Dutch providers examined the prevalence and duration of clinicians' symptoms associated with involvement in an adverse event as well as the relationship between the degree of harm and symptom duration. As expected, clinicians reported symptoms such as hypervigilance, self-doubt, and discomfort following adverse events. These symptoms were more severe and long lasting for events with more serious harm to patients, compared to events with less severe harm. The authors call for organizations to provide support for clinicians involved in adverse events. A previous PSNet perspective discussed efforts to ameliorate the impact of errors on providers.
Lake ET, Roberts KE, Agosto PD, et al. J Patient Saf. 2021;17:e1546-e1552.
The nursing work environment affects patient safety. This cross-sectional study surveyed nearly 2000 pediatric acute care nurses about their work environment and safety culture. Researchers measured the hospital work environment using a validated scale, and they assessed safety using the AHRQ Survey on Patient Safety Culture. A culture of blame and fear of speaking up remained prevalent among nurses participating in this survey. As with prior studies, investigators found an association between a high-functioning work environment and positive safety culture. The authors recommend enhancing pediatric acute care work environments for nurses in order to improve patient safety. A previous PSNet interview discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Griffiths P, Maruotti A, Saucedo AR, et al. BMJ Qual Saf. 2019;28:609-617.
There is a clear link between nurse staffing ratios and patient safety. This study corroborates the finding that lower registered nurse staffing and higher numbers of patients admitted per nurse are associated with increased rates of in-hospital mortality. The results underscore the importance of adequate nursing to ensure safe acute care.
Griffiths P, Ball JE, Bloor K, et al. Southampton, UK: NIHR Journals Library; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Sloane DM, Smith HL, McHugh MD, et al. Med Care. 2018;56:1001-1008.
Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient safety.
Aiken LH, Sloane DM, Barnes H, et al. Health Aff (Millwood). 2018;37:1744-1751.
Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
… as a key foundation for a safe system of care. … JaneBall, PhD … Principal Research Fellow University of … 1998;3:24-32. 4. Ball JE, Murrells T, Rafferty AM, Morrow E, Griffiths P. 'Care left undone' during nursing shifts: …
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.