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In hospital intensive care units, the report urged one RN for every two patients.

Croteau, however, said staff ratios are the one IOM report provision with which he disagrees. "The Joint Commission does not support the concept of predetermined ratios of caregiver to patients. Staffing is a lot more complex than that," he said.

Gelinas is of the same mind: "I do not believe in ratios," she said. "In a consensus of the nursing profession, nurse-patient ratios are not adequate to detail staffing. The two parameters as measures are nursing hours per patient day and skill mix, but not ratios."

The IOM committee also called for publicly accessible state and federal report cards on facilities, with information to include "standardized, case-mix-adjusted information on the average hours per patient day of RN, licensed and nurse assistant care."

"The point is this," Gelinas said: "Hospitals that are well-run, that have low turnover rates and healthier bottom lines, from the nurses' standpoint, are safer hospitals. I'm perplexed at why we don't accept the amount of evidence that's there."

The IOM summed up the evidence this way: "Over the last two decades … changes have been focused largely on increasing efficiency and have been undertaken in ways that have damaged trust between nursing staff and management … so that the intended results have not been achieved."

Speaking up

In a variety of ways, the report said, nurses have been hushed. Yet they are in a perfect position to determine staffing needs as well as to identify inefficiencies and practices that may contribute to medication and other errors. The committee said nurses rarely have, but should have, the authority to halt admissions or transfers to units when patient loads threaten to tax staff and test the limits of patient safety.

The IOM wants to reinvigorate nurse managers, whose numbers have fallen as financial pressures in health care have risen. It's not uncommon for a manager to oversee multiple units, a situation the report said "hampers nurses' ability to fix problems in their work environments that threaten patient safety."

A step up from nurse managers, the IOM said chief nursing officers should be on par with other administrators and that nursing must be part of the equation in executive decisions. It's then incumbent on leadership to create a culture of support for nurses, the report said.

The essence of patient safety lives in that culture.

Take medication errors, for instance. The IOM noted that nurses intercept 86 percent of medication errors. But with the right steps, that number can be better and there can be fewer errors to catch.

One step is limiting nurses' hours. "The work hours of a minority of nurses, in particular, are identified as a serious threat to the safety of patients," the report committee said. It recommended that states prohibit nurses from "patient care in any combination of scheduled shifts, mandatory overtime or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per seven-day period."

The trucking and airline industries have long recognized fatigue as a threat to safety and have widely accepted limits on work hours, said Hedy Cohen, RN, vice president of the independent Institute for Safe Medication Practices [www.ismp.org] in Huntingdon Valley, Pa.

Among other things, the institute publishes newsletters on medication errors, including one that is free of charge to RNs. The effect of fatigue on nurses is analogous to having one or two alcoholic drinks, Cohen said: "Your thought process and your coordination are decreased."

The IOM agreed: "The effects of fatigue include slowed reaction time, lapses of attention to detail, errors of omission, compromised problem-solving, reduced motivation and decreased energy for successful completion of required tasks."

Another step is for nurse managers with adequate resources to work with direct care nurses in areas where errors commonly occur: monitoring patients, transfers and patient hand-offs, complex processes and tasks that take nurses away from care. Locating and obtaining supplies, looking for personnel, doing redundant or unnecessary documentation and compensating for poor communication systems all detract from nurses' primary work and contribute to errors.