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It's here, too, that the report said, "Other nursing work processes, such as medication administration, are often carried out in ways that are conducive to the commission of errors and without the support of newer technologies that can prevent errors in medication administration." Although charting is not intrinsically dangerous to patients, the report noted that nurses spend as much as 28 percent of their time documenting patient information and care.

• Organizational culture, to encourage reporting of errors, analysis and prevention. The report points to studies that say between 34 percent and 38 percent of medication errors occur in nursing roles, such as administering drugs.

"The committee wishes to underscore that none of these recommendations is 'less important,' " said the report, which was headed by Donald Steinwachs, Ph.D., chairman of the department of health policy and management at the Bloomberg School of Public Health, Johns Hopkins University in Baltimore.

But asked to prioritize the recommendations, two patient safety experts in separate interviews seized on the nursing shortage and especially the need to reduce the RN turnover rate to increase patient safety. Turnover often is a reflection of management, workforce deployment and work design.

"The whole IOM report is a continuing plea to the industry to understand that we do not have safe systems," said Lillee Gelinas, MSN, RN, vice president and chief nursing officer of VHA Inc., an Irving, Texas-based cooperative intent on operational and clinical best practices in its 2,200-plus community hospitals. The organization has network hospitals in every state except Nevada and Utah.

Richard Croteau, MD, was a patient safety expert long before it was a marquee issue and said the IOM committee's report is "a very strong movement in the right direction." For the past eight years, Croteau has been executive director for strategic initiates for the Joint Commission on Accreditation of Healthcare Organizations.

Role of retention

In a sign that Croteau and Gelinas are on target with their emphasis on staffing, the IOM committee called on direct care nurses to help identify causes of turnover and develop ways to retain RNs.

"I would put retention right near the top" in patient safety, Croteau said. "A very common factor in adverse events has to do with incompleteness of the orientation process. The more stable your staff, the less you have to rely on orientation in the first place," whether it is for new hires, RNs floating among units or temporary staff, he said.

In a broad section titled "Maximizing Workforce Capability," the committee recommended that management set aside a percentage of nursing payroll for orientation and education, particularly as new technology is introduced. It also advised an annual, individual educational development plan for each nurse and nurse assistant.

Gelinas, whose network encompasses 246,000 nurses-205,000 of them RNs-called hospitals "recruiting machines."

"They do a great job at recruiting. They do a poor job at retaining and that's where the costs are and that's where the patient safety issues are," she said. "Hospitals with higher turnover have more patient deaths and higher lengths of stay.

"For the most part in health care today, the cultures are cultures of cost-cutting because our reimbursement pressures have been so great. But we have to change … to a culture of retention."

Within her own network and its Tomorrow's Workforce Initiative, Gelinas said it was an eye-opener to discover that turnover of RNs with less than two years' experience was 45 percent to 55 percent. The nursing profession recognizes a figure nowhere near that, she said, which can be blamed on inconsistent reporting standards. Some facilities include retirements and promotions in turnover, but others do not, Gelinas said.

"Use of nurses from external agencies should be avoided," the IOM committee said, as it recommended establishing cross-trained float pools of staff RNs to deal with fluctuations in patient volume on units. It added that preceptors should be assigned to nurses, experienced or otherwise, who are practicing in areas new to them.

The committee also called for updating the 1990 federal nurse-patient ratios, especially for nursing homes where the requirement is only one licensed nurse at all times in a facility, regardless of patient census. At a minimum in nursing homes, the IOM committee backed one RN for every 32 patients, one licensed nurse for every 18 patients and one nurse assistant for every 8.5 patients. No federal standard exists for nurse assistants.