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Patient safety

• Around 1 in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe care. In low-to-middle income countries, as many as 4 in 100 people die from unsafe care (1).
• Above 50% of harm (1 in every 20 patients) is preventable; half of this harm is attributed to medications (2,3).
• Some estimates suggest that as many as 4 in 10 patients are harmed in primary and ambulatory settings, while up to 80% (23.6–85%) of this harm can be avoided (4).
• Common adverse events that may result in avoidable patient harm are medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism.
• Patient harm potentially reduces global economic growth by 0.7% a year. On a global scale, the indirect cost of harm amounts to trillions of US dollars each year (1).
• Investment in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes (5). An example of a good return on investment is patient engagement, which, if done well, can reduce the burden of harm by up to 15% (4).

“First, do no harm” is the most fundamental principle of any health care service. No one should be harmed in health care; however, there is compelling evidence of a huge burden of avoidable patient harm globally across the developed and developing health care systems. This has major human, moral, ethical and financial implications.

Patient safety is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum." Within the broader health system context, it is “a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur."

Common sources of patient harm

Medication errors. Medication-related harm affects 1 out of every 30 patients in health care, with more than a quarter of this harm regarded as severe or life threatening. Half of the avoidable harm in health care is related to medications (3) .

Surgical errors. Over 300 million surgical procedures are performed each year worldwide (6) . Despite awareness of adverse effects, surgical errors continue to occur at a high rate; 10% of preventable patient harm in health care was reported in surgical settings (2) , with most of the resultant adverse events occurring pre- and post-surgery (7) .

Health care-associated infections. With a global rate of 0.14% (increasing by 0.06% each year), health care-associated infections result in extended duration of hospital stays, long-standing disability, increased antimicrobial resistance, additional financial burden on patients, families and health systems, and avoidable deaths (8) .

Sepsis. Sepsis is a serious condition that happens when the body’s immune system has an extreme response to an infection. The body’s reaction causes damage to its own tissues and organs. Of all sepsis cases managed in hospitals, 23.6% were found to be health care associated, and approximately 24.4% of affected patients lost their lives as a result (9) .

Diagnostic errors. These occur in 5–20% of physician–patient encounters (10,11) . According to doctor reviews, harmful diagnostic errors were found in a minimum of 0.7% of adult admissions (12) . Most people will suffer a diagnostic error in their lifetime (13) . 

Patient falls. Patient falls are the most frequent adverse events in hospitals (14) . Their rate of occurrence ranges from 3 to 5 per 1000 bed-days, and more than one third of these incidents result in injury (15) , thereby reducing clinical outcomes and increasing the financial burden on systems (16) .

Venous thromboembolism. More simply known as blood clots, venous thromboembolism is a highly burdensome and preventable cause of patient harm, which contributes to one third of the complications attributed to hospitalization (17) .

Pressure ulcers. Pressure ulcers are injuries to the skin or soft tissue. They develop from pressure to particular parts of the body over an extended period. If not promptly managed, they can have fatal complications. Pressure ulcers affect more than 1 in 10 adult patients admitted to hospitals (18) and, despite being highly preventable, they have a significant impact on the mental and physical health of individuals, and their quality of life. 

Unsafe transfusion practices. Unnecessary transfusions and unsafe transfusion practices expose patients to the risk of serious adverse transfusion reactions and transfusion-transmissible infections. Data on adverse transfusion reactions from a group of 62 countries show an average incidence of 12.2 serious reactions per 100 000 distributed blood components.

Patient misidentification. Failure to correctly identify patients can be a root cause of many problems and has serious effects on health care provision. It can lead to catastrophic adverse effects, such as wrong-site surgery. A report of the Joint Commission published in 2018 identified 409 sentinel events of patient identification out of 3326 incidents (12.3%) between 2014 and 2017 (19) .

Unsafe injection practices. Each year, 16 billion injections are administered worldwide, and unsafe injection practices place patients and health and care workers at risk of infectious and non-infectious adverse events. Using mathematical modelling, a study estimated that, in a period of 10 years (2000–2010), 1.67 million hepatitis B virus infections, between 157 592 and 315 120 hepatitis C virus infections, and between 16 939 and 33 877 HIV infections were associated with unsafe injections (20) . 

Factors leading to patient harm

Patient harm in health care due to safety breaks is pervasive, problematic and can occur in all settings and at all levels of health care provision. There are multiple and interrelated factors that can lead to patient harm, and more than one factor is usually involved in any single patient safety incident:

• system and organizational factors: the complexity of medical interventions, inadequate processes and procedures, disruptions in workflow and care coordination, resource constraints, inadequate staffing and competency development;
• technological factors: issues related to health information systems, such as problems with electronic health records or medication administration systems, and misuse of technology;
• human factors and behaviour: communication breakdown among health care workers, within health care teams, and with patients and their families, ineffective teamwork, fatigue, burnout, and cognitive bias;
• patient-related factors: limited health literacy, lack of engagement and non-adherence to treatment; and
• external factors: absence of policies, inconsistent regulations, economic and financial pressures, and challenges related to natural environment.

System approach to patient safety

Most of the mistakes that lead to harm do not occur as a result of the practices of one or a group of health and care workers but are rather due to system or process failures that lead these health and care workers to make mistakes.

Understanding the underlying causes of errors in medical care thus requires shifting from the traditional blaming approach to a more system-based thinking. In this, errors are attributed to poorly designed system structures and processes, and the human nature of all those working in health care facilities under a considerable amount of stress in complex and quickly changing environments is recognized. This is done without overlooking negligence or misbehaviour from those providing care that leads to substandard medical management. 

A safe health system is one that adopts all necessary measures to avoid and reduce harm through organized activities, including: 

• ensuring leadership commitment to safety and creation of a culture whereby safety is prioritized;
• ensuring a safe working environment and the safety of procedures and clinical processes;
• building competencies of health and care workers and improving teamwork and communication;
• engaging patients and families in policy development, research and shared decision-making; and 
• establishing systems for patient safety incident reporting for learning and continuous improvement. 

Investing in patient safety positively impacts health outcomes, reduces costs related to patient harm, improves system efficiency, and helps in reassuring communities and restoring their trust in health care systems (4,5) .

WHO response

Global action on patient safety.

Recognizing patient safety as a global health priority, and as an essential component of strengthening health systems for moving towards universal health coverage, the Seventy-second World Health Assembly adopted resolution WHA72.6 on “Global action on patient safety” in May 2019. 

The resolution requested the Director-General to emphasize patient safety as a key strategic priority in WHO’s work across the universal health coverage agenda, endorsed the establishment of World Patient Safety Day to be observed annually on 17 September, and requested WHO’s Director-General to develop a global patient safety action plan with the involvement of WHO Member States, partners and other relevant stakeholders. 

Global Patient Safety Action Plan 2021–2030

The Global Patient Safety Action Plan 2021–2030 provides a framework for action for key stakeholders to join efforts and implement patient safety initiatives in a comprehensive manner. The goal is “to achieve the maximum possible reduction in avoidable harm due to unsafe health care globally”, envisioning “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere”. 

• World Patient Safety Day

Since 2019, World Patient Safety Day has been celebrated across the world annually on 17 September, calling for global solidarity and concerted action by all countries and international partners to improve patient safety. The global campaign, with its dedicated annual theme, is aimed at enhancing public awareness and global understanding of patient safety and mobilizing action by stakeholders to eliminate avoidable harm in health care and thereby improve patient safety. 

WHO Flagship initiative “A Decade of Patient Safety 2021–2030” 

WHO has launched the Patient Safety Flagship as a transformative initiative to guide and support strategic action on patient safety at the global, regional and national levels. Its core work involves supporting the implementation of the Global Patient Safety Action Plan 2021–2030. 

1. Slawomirski L, Klazinga N. The economics of patient safety: from analysis to action. Paris: Organisation for Economic Co-operation and Development; 2020 ( http://www.oecd.org/health/health-systems/Economics-of-Patient-Safety-October-2020.pdf , accessed 6 September 2023).

2. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185. doi:10.1136/bmj.l4185.

3. Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020;18(1):1–3.

4. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety in primary and ambulatory care: flying blind. OECD Health Working Papers No. 106. Paris: Organisation for Economic Co-operation and Development; 2018 ( https://doi.org/10.1787/baf425ad-en , accessed 6 September 2023).

5. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. OECD Health Working Papers No. 96. Paris: Organisation for Economic Co operation and Development; 2017 ( https://doi.org/10.1787/5a9858cd-en , accessed 6 September 2023).

6. Meara, John G., Andrew JM Leather, Lars Hagander, Blake C. Alkire, Nivaldo Alonso, Emmanuel A. Ameh, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The lancet. 2015; 386: 569-624

7. Rodziewicz TL, Houseman B, Hipskind JE. Medical error reduction and prevention. Treasure Island, FL: StatPearls Publishing; 2023.

8. Raoofi S, Kan FP, Rafiei S, Hosseinipalangi Z, Mejareh ZN, Khani S et al. Global prevalence of nosocomial infection: a systematic review and meta-analysis. PLoS One. 2023;18(1):e0274248.

9. Markwart R, Saito H, Harder T, Tomczyk S, Cassini A, Fleischmann-Struzek C et al. Epidemiology and burden of sepsis acquired in hospitals and intensive care units: a systematic review and meta-analysis. Intensive Care Med. 2020;46(8):1536–51. doi:10.1007/s00134-020-06106-2. 

10. National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. Washington (DC): National Academies Press; 2015 ( https://doi.org/10.7326/M15-2256 , accessed 6 September 2023).

11. Bergl PA, Nanchal RS, Singh H. Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety. Ann Am Thorac Soc. 2018;15(8):903–7.

12. Gunderson CG, Bilan VP, Holleck JL, Nickerson P, Cherry BM, Chui P et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. BMJ Qual Saf. 2020;29(12):1008–18.

13. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23(9):727–31. 

14. LeLaurin JH, Shorr RI. Preventing falls in hospitalized patients: state of the science. Clin Geriatr Med. 2019;35(2):273–83.

15. Agency for Healthcare Research and Quality. Falls. PSNet; 2019. (https://psnet.ahrq.gov/primer/falls, accessed 11 September 2023).

16. Dykes PC, Curtin-Bowen M, Lipsitz S, Franz C, Adelman J, Adkison L et al. Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. JAMA Health Forum. 2023;4(1):e225125. doi:10.1001/jamahealthforum.2022.5125. 

17. Raskob GE, Angchaisuksiri P, Blanco AN, Buller H, Gallus A, Hunt BJ et al. Thrombosis: a major contributor to global disease burden. Arterioscler Thromb Vasc Biol. 2014;34(11):2363–71. doi:10.1161/ATVBAHA.114.304488.

18. Li Z, Lin F, Thalib L, Chaboyer W. Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. International journal of nursing studies. 2020 May 1;105:103546.

19. De Rezende HA, Melleiro MM, Shimoda GT. Interventions to reduce patient identification errors in the hospital setting: a systematic review protocol. JBI Evidence Synthesis. 2019;17(1):37–42.

20. Pèpin J, Chakra CN, Pèpin E, Nault V, Valiquette L. Evolution of the global burden of viral infections from unsafe medical injections, 2000–2010. PLoS One. 2014;9(6):e99677.

• Global Patient Safety Action Plan 2021-2030
• The conceptual framework for the international classification for patient safety
• 10 facts on patient safety
• Global Ministerial Summits on Patient Safety
• Global patient safety report 2024
• Antimicrobial resistance
• Blood safety and availability
• Infection prevention and control
• Radiation safety
• Universal health coverage

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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 1 defining patient safety and quality care.

Pamela H. Mitchell .

Affiliations

• Introduction

The goal of this chapter is to provide some fundamental definitions that link patient safety with health care quality. Evidence is summarized that indicates how nurses are in a key position to improve the quality of health care through patient safety interventions and strategies.

• Quality Care

Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.” 1 Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world. 2 Harteloh 3 reviewed multiple conceptualizations of quality and concluded with a very abstract definition: “Quality [is] an optimal balance between possibilities realised and a framework of norms and values.” This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities).

Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” 4 This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. Theses standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds—death, disease, disability, discomfort, and dissatisfaction 5 —rather than more positive components of quality.

The work of the American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs. 6 , 7 The latter indicators were outlined more fully by the National Quality Forum. 8 Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators.

The most recent IOM work to identify the components of quality care for the 21st century is centered on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centered, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built. 9

• Patient Safety

A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient safety was defined by the IOM as “the prevention of harm to patients.” 1 Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients. 1 , 10 The glossary at the AHRQ Patient Safety Network Web site expands upon the definition of prevention of harm: “freedom from accidental or preventable injuries produced by medical care.” 11

Patient safety practices have been defined as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.” 12 This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm. Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows: 12

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
• Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
• Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
• Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding
• Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
• Use of pressure-relieving bedding materials to prevent pressure ulcers
• Use of real-time ultrasound guidance during central line insertion to prevent complications
• Patient self-management for warfarin (Coumadin®) to achieve appropriate outpatient anticoagulation and prevent complications
• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications
• Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections

Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research. 12 Review of evidence to date critical for the practice of nursing can be found in later chapters of this Handbook.

The National Quality Forum attempted to bring clarity and concreteness to the multiple definitions with its report, Standardizing a Patient Safety Taxonomy . 13 This framework and taxonomy defines harm as the impact and severity of a process of care failure: “temporary or permanent impairment of physical or psychological body functions or structure.” Note that this classification refers to the negative outcomes of lack of patient safety; it is not a positive classification of what promotes safety and prevents harm. The origins of the patient safety problem are classified in terms of type (error), communication (failures between patient or patient proxy and practitioners, practitioner and nonmedical staff, or among practitioners), patient management (improper delegation, failure in tracking, wrong referral, or wrong use of resources), and clinical performance (before, during, and after intervention).

The types of errors and harm are further classified regarding domain, or where they occurred across the spectrum of health care providers and settings. The root causes of harm are identified in the following terms: 8

• Latent failure—removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources
• Active failure—direct contact with the patient
• Organizational system failure—indirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors
• Technical failure—indirect failure of facilities or external resources

Finally, a small component of the taxonomy is devoted to prevention or mitigation activities. These mitigation activities can be universal (implemented throughout the organization or health care settings), selective (within certain high-risk areas), or indicated (specific to a clinical or organizational process that has failed or has high potential to fail).

• Nursing As the Key to Improving Quality Through Patient Safety

Nursing has clearly been concerned with defining and measuring quality long before the current national and State-level emphasis on quality improvement. Florence Nightingale analyzed mortality data among British troops in 1855 and accomplished significant reduction in mortality through organizational and hygienic practices. 14 She is also credited with creating the world’s first performance measures of hospitals in 1859. In the 1970s, Wandelt 15 reminded us of the fundamental definitions of quality as characteristics and degrees of excellence, with standards referring to a general agreement of how things should be (to be considered of high quality). About the same time, Lang 16 proposed a quality assurance model that has endured with its foundation of societal and professional values as well as the most current scientific knowledge (two decades before the IOM definition was put forth).

In the past, we have often viewed nursing’s responsibility in patient safety in narrow aspects of patient care, for example, avoiding medication errors and preventing patient falls. While these dimensions of safety remain important within the nursing purview, the breadth and depth of patient safety and quality improvement are far greater. The most critical contribution of nursing to patient safety, in any setting, is the ability to coordinate and integrate the multiple aspects of quality within the care directly provided by nursing, and across the care delivered by others in the setting. This integrative function is probably a component of the oft-repeated finding that richer staffing (greater percentage of registered nurses to other nursing staff) is associated with fewer complications and lower mortality. 17 While the mechanism of this association is not evident in these correlational studies, many speculate it is related to the roles of professional nurses in integrating care (which includes interception of errors by others—near misses), as well as the monitoring and surveillance that identifies hazards and patient deterioration before they become errors and adverse events. 18 Relatively few studies have had the wealth of process data evident in the RAND study of Medicare mortality before and after implementation of diagnosis-related groups. The RAND study demonstrated lower severity-adjusted mortality related to better nurse and physician cognitive diagnostic and treatment decisions, more effective diagnostic and therapeutic processes, and better nursing surveillance. 19 , 20

Further, when we consider the key role of communication or communication lapses in the commission of error, the role of nursing as a prime communication link in all health care settings becomes evident. The definition of “error chain” at PSNet clearly indicates the role of leadership and communication in the series of events that leads to patient harm. Root-cause analyses of errors provide categories of linked causes, including “(1) failure to follow standard operating procedures, (2) poor leadership, (3) breakdowns in communication or teamwork, (4) overlooking or ignoring individual fallibility, and (5) losing track of objectives.” 21 This evidence was used in developing the cause portion of the National Quality Forum’s patient safety taxonomy and is further discussed in other chapters of this book.

Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcomes of care, such as mortality and morbidity. Nurses are critical to the surveillance and coordination that reduce such adverse outcomes. Much work remains to be done in evaluating the impact of nursing care on positive quality indicators, such as appropriate self-care and other measures of improved health status.

• Cite this Page Mitchell PH. Defining Patient Safety and Quality Care. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 1.
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The Nurse-Patient Assignment

Purposes and decision factors.

Allen, Stephanie B. PhD, RN, NE-BC

Author Affiliation: Assistant Professor, Pace University, Pleasantville, New York.

The author declares no conflicts of interest.

Correspondence: Dr Allen, Lienhard School of Nursing, L310, 861 Bedford Rd, Pleasantville, NY 10570 ( [email protected] ).

OBJECTIVE: 

Identify purposes and decision factors of the nurse-patient assignment process.

BACKGROUND: 

Nurse-patient assignments can positively impact patient, nurse, and environmental outcomes.

METHODS: 

This was an exploratory study involving interviews with 14 charge nurses from 11 different nursing units in 1 community hospital.

RESULTS: 

Charge nurses identified 14 purposes and 17 decision factors of the nurse-patient assignment process.

CONCLUSIONS: 

The nurse-patient assignment is a complex process driven by the patient, nurse, and environment. Further study is needed to identify factors linked to patient safety, nurse, and environmental outcomes.

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Nursing and Patient Safety

Updated in March 2021. Originally published in December 2011 by researchers at the University of California, San Francisco.  PSNet primers are regularly reviewed and updated to ensure that they reflect current research and practice in the patient safety field.  

Nurses play a critically important role in ensuring patient safety while providing care directly to patients. While physicians make diagnostic and treatment decisions, they may only spend 30 to 45 minutes a day with even a critically ill hospitalized patient, which limits their ability to see changes in a patient’s condition over time. Nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families, and all other members of the health care team and are crucial to timely coordination and communication of the patient’s condition to the team. From a patient safety perspective, a nurse’s role includes monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, identifying and communicating changes in patient condition, and performing countless other tasks to ensure patients receive high-quality care.

Nurse staffing and patient safety

Nurse staffing ratios

Nurses' vigilance at the bedside is essential to their ability to ensure patient safety. It is logical, therefore, that assigning increasing numbers of patients eventually compromises a nurse’s ability to provide safe care. There are many key factors that influence nurse staffing such as patient acuity, admissions numbers, transfers, discharges, staff skill mix and expertise, physical layout of the nursing unit, and availability of technology and other resources. 1,2

Several seminal studies linked in this sentence have demonstrated the association between nurse staffing ratios and patient safety, documenting an increased risk of  patient safety events, morbidity, and even  mortality  as the number of patients per nurse increases. The strength of these data has led several states, beginning with California in 2004, to establish legislatively mandated minimum staffing ratios. According to the American Nurses Association , only 14 states have passed nurse staffing legislation as of March 2021 and most states do not specify registered-nurse (RN)-to-patient ratios, which vary by state and are also setting-dependent.

The nurse-to-patient ratio is only one aspect of the relationship between the nursing workload and patient safety . Overall nursing workload is likely linked to patient outcomes as well. A PSNet Classic 2011 study  showed that increased patient turnover was also associated with increased mortality risk, even when overall nurse staffing was considered adequate. Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis. It requires close coordination between management and nursing and is based on patient acuity and turnover, availability of support staff and skill mix, and settings of care. The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in detail in this WebM&M commentary .

Nurse staffing and settings of care

Acute Care Hospitals: The Centers for Medicare & Medicaid Services (CMS) requires hospitals to ensure that there are adequate numbers of licensed RNs, licensed vocational (practical) nurses (LVN), and other staff to provide nursing care to patients as needed (42 Code of Federal Regulations (42CFR 482.23(b)),but does not require specific ratios. Nurse-to-patient ratios are setting-dependent; while five patients per RN may be appropriate in the acute medical-surgical units, intensive care units have a ratio of one or two patients per RN, depending on the acuity of the patient. In California, the nurse patient ratio in the emergency department is one nurse to four patients. In recent years, more states are acknowledging that better staffing ratios are important to improved patient outcomes. In fact, Dall et al., 2009, found that there were economic benefits to hospitals with better staffing arising from decreased hospital length of stay. 3

Skilled Nursing Homes (NH) : For nursing homes where there are far fewer RNs, the ratio of nurses to patients or residents is measured in parts of an hour per resident day (hprd), typically appearing as a decimal. For example, in 2020 the national average was 0.75 hprd, which is the equivalent of ¾ of an hour, or 45 minutes, of RN time for each resident in the NH. There are many studies of nurse staffing in NHs in relation to quality and safety with varying results. However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract infections, less likelihood of hospitalizations, decreased mortality, and improved quality measure such as falls and moderate to severe pain. 4 The review also found improved satisfaction of nurses, which was associated with decreased turnover.  

Adequate nurse staffing depends on several factors such as lack of training, administrative demands, distractions, and interruptions that can impact nurse’s work. 5

Nurse staffing and education and training

Nursing skill mix and training appears to be linked to patient outcomes. One classic  study  showed lower inpatient mortality rates for a variety of surgical patients in hospitals with more highly educated nurses. This finding has resulted in calls for all nurses to have at least a baccalaureate education, which was one of four key recommendation of the landmark Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health . Irrespective of educational level, the quality of nurses' on-the-job training may also play a role in patient outcomes. As discussed in another  WebM&M commentary , nurses do not currently have a required standardized transition to independent practice training (analogous to medical residency training); however, in 2002, the University HealthSystem Consortium and American Association of Colleges of Nursing (UHC/AACN) launched the first formal, standardized 12-month long RN residency program with six sites. After the Future of Nursing Report (2010) recommended nurse residencies, the program grew to 60 sites with residents. In 2021, all but five states had established nurse residency programs and those last five states were pending the start of the program. With over 93,000 nurses trained in the residency program, the 2018 registered nurse retention rate after one year of residency was 91.5%, compared with the national average of 82.5% of nurses without residency training retained after one year. 6  

Nurses' working conditions and patient safety

The causal relationship between nurse-to-patient ratios and patient outcomes likely is accounted for by both increased workload and stress, and the risk of burnout for nurses. The high-intensity nature of nurses' work means that nurses themselves are at risk of committing errors while providing routine care.  Human factors engineering  principles hold that when an individual is attempting a complex task, such as administering medications to a hospitalized patient, the work environment should be as conducive as possible to carrying out that task. However,  operational failures  such as interruptions or equipment failures may interfere with nurses' ability to safely and effectively perform such tasks; several  studies  have shown that interruptions are virtually a routine part of nurses' jobs. These interruptions have been tied to an increased risk of errors, particularly  medication administration errors . While some interruptions are an entrenched part of patient care, the link between interruptions and errors is one example of how deficiencies in the day-to-day work environment for nurses is directly linked to patient safety.

Longer shifts and working overtime have also been linked to increased risk of error, including in one high-profile  case  where an error committed by a nurse working a double shift resulted in the nurse being criminally prosecuted. Studies show that medication errors are three times more likely to be committed by a nurse working shifts longer than 12.5 hours each on more than two consecutive days. 7 Fatigue results in inattention, a decline in vigilance, poor judgment, and lack of concentration. 

Nurses who commit errors are also at risk of becoming  second victims of the error, a well-documented phenomenon that is associated with an increased risk of self-reported error and leaving the nursing profession. In their daily work, nurses are frequently exposed to  disruptive or unprofessional behavior  by physicians and other health care personnel, and such exposure has been  demonstrated  to be a key factor in nursing burnout and in nurses leaving their jobs or leaving the profession entirely.

Transformational leadership , personal accountability , teamwork, staffing ratios , and practice environments each have relevance to patient safety as carried out by nurses. 8 These themes are encompassed within an understanding of human factors, which can either facilitate, or be a barrier to, nurses completing all tasks and addressing all care within the time allotted. Under a transformational leadership structure, nurses can practice at optimal levels, motivated by supervisors who encourage critical thinking, foster skill development, and increase work satisfaction on the team, thus promoting better patient outcomes. A nurse who holds himself or herself personally accountable for maintaining a culture of safety may be less likely to have a missed nursing care episode. 9  

"Missed" nursing care

Missed nursing care is a phenomenon of omission that occurs when the right action is delayed, is partially completed, or cannot be performed at all. In one British study , missed nursing care episodes were strongly associated with a higher number of patients per nurse. Missed nursing care errors have been identified as common and universal and secondary to systemic factors that bring undesirable consequences for both patients and nursing professionals. Omission of care has been linked to both job dissatisfaction and absenteeism for nurses, as well as to medication errors, infections, falls, pressure injuries, readmissions, and failure to rescue . 10 In addition, If bullying is present within the workplace, more nurses are likely to self-report missed nursing care. 11  

When evaluating cause and prevention of missed nursing care, the most consistent predictors of omission errors include staffing levels, work environment, and teamwork. 12,13 Several conclusions can be drawn from examining missed nursing care through the lens of nursing-sensitive indicators. Missed nursing care is predominantly a structural issue of competing priorities and time pressure; therefore, adequate staffing is paramount. Organizational and unit culture promote teamwork and lead to nursing job satisfaction that is likely to reduce the pressures associated with omitted work. Strong process measures that focus on standardizing care improve outcomes, such as reduced falls and pressure injuries. Outcome measures such as Ventilator Acquired Pneumonia bundles can inform nurses on nursing care processes.

Safety and Quality Rating Systems

The National Quality Forum endorsed voluntary consensus  standards  for nursing-sensitive care in 2004. These included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the quality of the nursing practice environment (which includes staffing ratios), and nursing turnover. These measures are intended to illustrate both the quality of nursing care and the degree to which an institution’s working environment supports nurses in their patient safety efforts. Nurse-sensitive indicators are a metric for the degree to which acute care hospitals provide quality, patient safety, and promote a safe and professional work environment. Nurse-sensitive measures continue to set the standard for quality and safety in care in the acute scare setting. As of 2021, there are 39-nurse sensitive measures. Magnet Hospital Recognition

The Magnet Hospital Recognition , administered by the American Nurses Credentialing Center, is a recognition program acknowledging hospitals that deliver superior patient care and also attract and retain high-quality nurses. Beginning in 1983, the program sought to identify hospitals which had lower turnover rates and above average retention for nurses. This primer has identified institutional characteristics which correlate with higher retention rates. These characteristics are identified by Magnet as a pathway to excellence and include items such as professional development, continuing education, shared decision making, quality, well-being, and leadership.

Public Reporting

In the past decade, public reporting of quality data has mushroomed. Two sources of this data, Hospital Compare and Nursing Home Compare websites, are created jointly by CMS and the Hospital Quality Alliance, and geared toward providing consumer data on the degree to which hospitals provide recommended care to their patients. The goal was to facilitate easy access to quality data for consumers to be able to make informed decisions. Types of data provided to consumers relevant to nursing care include patient experience, timely and effective care, and nurse staffing. In October of 2019, CMS created the Five-Star Quality Rating System to help patients, families, and caregivers navigate quality in the nurse home setting. This rating system gives each organization (e.g., hospital or nursing home) a star score from 1 to 5 based on areas such as nurse staffing and quality measures.

The multiple factors discussed including the high-risk nature of the work, increased stress caused by workload and interruptions, and the risk of burnout due to involvement in errors, the second victim phenomenon, or exposure to disruptive behavior—likely combine with unsafe conditions precipitated by low nurse-to-patient staffing ratios to increase the risk of adverse events. Using a  systems analysis  perspective, active errors made by individual nurses likely combine with these aligned holes in the " Swiss Cheese Model of Medical Errors " to result in preventable harm to patients.

Alex Peck Malliaris, MSN, MSHCA, FNP-C Nurse Practitioner Resident UC Davis Health

Jessamyn Phillips, DNP, FNP-C Nurse Practitioner Resident UC Davis Health

Deb Bakerjian PhD, APRN Co-Editor-in-Chief, AHRQ's Patient Safety Network (PSNet) Clinical Professor Betty Irene Moore School of Nursing UC Davis Health

• Sloane DM, Smith HL, McHugh MD, et al. Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study.  Med Care . 2018;56(12):1001-1008. [ Free full text ]
• Needleman J, Buerhaus P, Pankratz VS, et al. Nurse staffing and inpatient hospital mortality.  N Engl J Med . 2011;364(11):1037-1045. [ Free full text ]
• Vizient/AACN Nurse Residency Program  https://www.aacnnursing.org/Portals/42/AcademicNursing/NRP/Nurse-Residency-Program.pdf  Accessed April 2022.
• Dall TM, Chen YJ, Seifert RF, et al. The economic value of professional nursing.  Med Care . 2009;47(1):97-104. [ Available at ]
• Dellefield ME, Castle NG, McGilton KS, et al. The relationship between registered nurses and nursing home quality: an integrative review (2008-2014). Nurs Econ . 2015;33(2):95-108. [ Free full text ]
• Monteiro C, Avelar AF, Pedreira MD. Interruptions of nurses' activities and patient safety: an integrative literature review. Rev Lat Am Enfermagem . 2015;23(1):169-79. [ Free full text ]
• Di Muzio M, Dionisi S, Di Simone E, et al. Can nurses’ shift work jeopardize the patient safety? A systematic review. Eur Rev Med Pharmacol Sci. 2019;23(10):4507-19. [ Free full text ]
• Boamah SA, Spence Laschinger HK, Wong C, et al. Effect of transformational leadership on job satisfaction and patient safety outcomes. Nurs Outlook . 2018;66(2):180–9. [ Available at ]
• Srulovici E, Drach-Zahavy A. Nurses’ personal and ward accountability and missed nursing care: a cross-sectional study. Int J Nurs Stud . 2017;75:163–71. [ Available at ]
• Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs . 2009;65(7):1509-17. [ Free full text ]
• Hogh A, Baernholdt M, Clausen T. Impact of workplace bullying on missed nursing care and quality of care in the eldercare sector. Int Arch Occup Environ Health . 2018;91(8):963–70. [ Available at ]
• Park SH, Hanchett M, Ma C. Practice environment characteristics associated with missed nursing care. J Nurs Scholarsh . 2018;50(6):722–30. [ Free full text ]
• Bragadóttir H, Kalisch BJ, Tryggvadóttir GB. Correlates and predictors of missed nursing care in hospitals. J Clin Nurs . 2017;26(11-12):1524-34. [ Free full text ]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

WebM&M Cases

Patient Safety Primers

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Personal health literacy, long-term care and patient safety.

Clinical alarms: complexity and common sense. June 21, 2006

Post-Acute Transitional Services: Safety in Home-Based Care Programs

Simulation training.

2017 John M. Eisenberg Patient Safety and Quality Awards. July 18, 2018

The Safety and Quality of Health Care: Where are We Now? June 7, 2006

Navigating the perfect storm: balancing a culture of safety with workforce challenges. January 23, 2008

Supplemental Issue: Quality and Safety Education for Nurses (QSEN) program. September 6, 2017

Language Barriers in Health Care. February 6, 2008

Health Information Technology. February 4, 2015

Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program. October 29, 2014

Still Crossing The Quality Chasm. April 20, 2011

Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme. May 1, 2024

Perspective

Why do nurses miss nursing care? A qualitative meta-synthesis. April 24, 2024

A qualitative study of systems-level factors that affect rural obstetric nurses' work during clinical emergencies. February 21, 2024

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: a scoping review. January 24, 2024

Fragmented: A Doctor's Quest to Piece Together American Health Care. September 27, 2023

Global Knowledge Sharing Platform for Patient Safety. September 20, 2023

In search of an international multidimensional action plan for second victim support: a narrative review. September 13, 2023

Strategies to Improve Organizational Health Literacy.

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study. May 3, 2023

Annual Perspective

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. February 15, 2023

Self-assessment and learning motivation in the second victim phenomenon. February 1, 2023

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction. January 25, 2023

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic. November 30, 2022

Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators. October 5, 2022

Exploring care left undone in pediatric nursing. September 28, 2022

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study. June 22, 2022

Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic. February 23, 2022

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation. December 15, 2021

Training Program for Nurses on Shift Work and Long Work Hours. October 10, 2021

Coping strategies in health care providers as second victims: a systematic review. August 4, 2021

Healthcare personnel's working conditions in relation to risk behaviours for organism transmission: a mixed-methods study. July 21, 2021

Missed nursing care during the COVID-19 pandemic: a comparative observational study. July 21, 2021

Nurses as 'second victims' to their patients' suicidal attempts: a mixed-method study. June 30, 2021

Cancer diagnoses delayed among prisoners in Washington state. May 26, 2021

Smartphone distraction during nursing care: systematic literature review. April 7, 2021

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Questions to Ask in Making the Decision to Accept a Staffing Assignment for Nurses

Registered nurses need to know their rights and responsibilities when considering a patient assignment. If you feel that you lack expertise on a unit and patient population, you don’t just have the right to refuse an assignment there, you have an obligation to do so. Your case managers should never ask you to work with patients you aren’t qualified to have in your care. There are many factors to consider before accepting a new patient assignment.

This set of questions can help guide you through decisions about nurse staffing assignments .

• What is the assignment? Clarify what is expected. Do not assume. Be certain in the details.
• What are the characteristics of the patients being assigned? Don’t just respond to the number of patients; make a critical assessment of the needs of each patient, complexity, stability, and acuity and the resources available to meet those needs.
• Do you have the expertise to care for the patients? Are you familiar with caring for the types of patients assigned? If this is a “float assignment,” are you crossed-trained to care for these patients? Is there a “buddy system” in place with staff who are familiar with the unit? If there is no cross-training or “buddy system,” has the patient load been modified accordingly?
• Do you have the experience and knowledge to manage the patients for whom you are being assigned care? If the answer to the question is “no,” you have an obligation to articulate your limitations. Limitations in experience and knowledge may not require refusal of the assignment, but rather an agreement regarding supervision or a modification of the assignment to ensure patient safety. If no accommodation for limitations is considered, the nurse has an obligation to refuse an assignment for which she or he lacks education or experience.
• What is the geography of the assignment? Are you being asked to care for patients who are in close proximity for efficient management, or are the patients at opposite ends of the hall or in different units? If there are geographic difficulties, what resources are available to manage the situation? If the patients are in more than one unit and you must go to another unit to provide care, who will monitor patients out of your immediate attention?
• Is this a temporary assignment? When other staff are located to assist, will you be relieved? If the assignment is temporary, it may be possible to accept a difficult assignment, knowing that there will soon be reinforcements. Is there a pattern of short staffing, or is this truly an emergency?
• Is this a crisis or an ongoing staffing pattern? If the assignment is being made because of an immediate need or crisis on the unit, the decision to accept the assignment may be based on that immediate need. However, if the staffing pattern is an ongoing problem, you have the obligation to identify unmet standards of care that are occurring as a result of ongoing staffing inadequacies. This may result in a request for “safe harbor” and/or peer review.
• Can you take the assignment in good faith? If not, you will need to get the assignment modified — or refuse the assignment. Consult your state’s nursing practice act regarding clarification of accepting an assignment in good faith. In understanding “good faith,” it’s sometimes easier to identify what would constitute bad faith. For example, if you have not taken care of pediatric patients since nursing school and you are asked to take charge of a pediatric unit, unless this is an extreme emergency, such as a disaster (in which case you would need to let people know your limitations, but you might still be the best person, given all factors for the assignment), it would be bad faith to take the assignment. It’s always your responsibility to articulate your limitations and to get an adjustment to the assignment that acknowledges the limitations you have articulated. Good-faith acceptance of an assignment means that you are concerned about the situation and believe that a different pattern of care or policy should be considered. However, you acknowledge the difference of opinion on the subject between you and your supervisor and are willing to take the assignment, and await the judgment of other peers and supervisors.

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