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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.
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.
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