The American Nurses Association (ANA) appreciates the opportunity to discuss our concerns regarding the topic of patient safety and medical errors. The issue of health care error is one of great importance to the nursing profession. Nurses have substantial contributions to make to efforts to reduce health care error, and it is critical for us to share our perspectives. ANA is the only full-service professional organization representing the nation's 2.6 million registered nurses, including staff nurses, nurse practitioners, clinical nurse specialists, certified nurse midwives and certified registered nurse anesthetists through its 53 state and territorial nurses associations.

The health care industry is undergoing rapid changes that transform systems into highly complex and sophisticated enterprises where scrutiny of patient satisfaction and patient outcomes is increasing. Many health care institutions are creating an atmosphere of "blame" in which individual health care providers are increasingly held accountable for adverse patient outcomes. Mistakes by health care providers are viewed as individual failings rather than as systems failures, and are dealt with in a punitive framework.

Nursing Management reports that health care organizations differ from other businesses in the level of complexity involved in running the organization. "At every organizational level, health care employees serve significantly more internal and external customers than their counterparts in the business world." (Murphy, Ruch, Pepicello and Murphy, 1997, p. 34) Natural outgrowths of an increasingly intricate health care delivery system are

1. unchecked complexities which place the patient at risk; and
2. problems which negatively impact the nurse.

"To Err is Human" describes a fragmented health care system this is prone to errors and detrimental to safe patient care. This problem is not new to registered nurses and the American Nurses Association. ANA has long recognized this problem and has worked to address issues related to nursing care that enhance patient safety and outcomes. Some examples of our work include the following:

• Nursing's Agenda for Health Care Reform (1990), reaffirmed in 1998, calls for the creation of a health system that meets the needs of patients and their families by delivering essential health services in familiar, convenient sites.
• Magnet Nursing Services Recognition Program recognizes excellence in the provision of nursing services and acknowledges those institutions committed to the delivery of quality nursing services. A 1982 study, conducted by the American Academy of Nursing, identified and described variables that created an environment that attracted and retained well-qualified nurses who promoted quality patient care through providing excellence in nursing services.
• Nursing-Sensitive Quality Indicators Initiative (1994), established through scientific research the connection between nursing interventions, nurse staffing levels, and positive patient outcomes. Preliminary studies comparing staffing information and information on patient outcomes show that when there are more registered nurses, patients experience fewer complications, shorter lengths of stay in the hospital, decreased mortality rates, and even lower overall costs.
• Principles for Nurse Staffing establishes parameters for examining appropriate staffing levels necessary for the delivery of quality patient care. Identifying and maintaining the appropriate number and mix of nursing staff is a problem experienced by nurses at every level in all settings.

The human cost of medical errors is high. Based on the findings of one major study, medical errors kill some 44,000 people in U.S. hospitals each year. Another study puts the number much higher, at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. Moreover, while errors may be more easily detected in hospitals, they afflict every health care setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, as well as home care. Deaths from medication errors that take place both in and out of hospitals — more than 7,000 annually — exceed those from workplace injuries.

The majority of medical errors do not result from individual recklessness but from basic flaws in the way the health system is organized. Stocking patient-care units in hospitals, for example, with certain full-strength drugs — even though they are toxic unless diluted — has resulted in deadly mistakes. And illegible writing in medical records has resulted in administration of a drug for which the patient has an known allergy. This evolving health care system often lacks adequate coordination. For example, when a patient is treated by several practitioners, they often do not have complete information about the medicines prescribed or the patient's illnesses.

In nursing practice, the scope of responsibility, independent judgment and decision-making has been expanded, while nurses' autonomy and decision-making abilities are more constrained as management systems focus on bottom-line profits over patient safety and quality. Nurses are the single largest labor cost for a hospital and therefore a likely target for cuts. Slashes in operating budgets have resulted in reduced utilization of professional nurses and nursing management oversight positions. These traditional management positions have been most directly responsible for assuring that adequate safety and quality systems are in place. Additionally, some hospital administrators have reasoned that since hospital admissions and lengths of stay have been reduced, fewer nurses are needed to provide patient care. This ignores the fact that the hospitalized patient population is more acutely ill requiring a higher intensity of care.

Thus, one of ANA's major concerns in the health care delivery system which relates to the prevention of adverse events is the adequacy and appropriateness of staffing. For some time, ANA, the State Nurses Associations (SNAs) and other nurses have identified elements of these troubling workplace trends. Separate studies conducted by ANA and Princeton Survey Research Associates (ANA and Princeton Survey Research Associates, 1996), the American Hospital Association (AHA, 1996) and the National Coalition of Health Care ("National coalition on health care," 1997) all revealed that patients were concerned about the care they were receiving in acute care institutions. Subsequently, the New York State Nurses Association published a report which indicated that nurses were caring for up to 15-30 seriously ill patients at a time, making it impossible to deliver quality care. Medication errors and falls were on the rise, RN disciplinary cases were mounting as were RN on-the-job injuries and use of sick time (New York State Nurses Association, 1997).

In spite of increasing evidence that systems failures, including inadequate and inappropriate staffing, are putting patients at risk, many health care systems continue to assign and emphasize individual "blame" for errors, misjudgments and patient dissatisfaction. Hospital systems and administrators are assuming that the appropriate way to deal with complexity and systems problems is to manage the workers — through oversight and discipline — as opposed to identifying and resolving the central problem in the spirit of partnership.

ANA has advocated for investigation of system changes that may result in egregious errors by individual practitioners, noting that health care systems have downsized, restructured and reorganized to the point where processes, initially put in place to protect the public, are breaking down.

The severity of discipline for practice errors has increased. For example, in a recent Colorado case, medication errors were no longer treated as the domain of the hospital and the state licensing board, but drew the attention of the media and the court systems. Three registered nurses were charged with criminally negligent homicide when a medication error resulted in the death of a child ("Colorado case blurs line", 1997). Health care organizations must approach problem solving strategies through shared accountability and partnership for quality improvement. A shared accountability approach diminishes focus on individual blaming and enhances long-rang process improvements.

The ANA agrees with the Institute of Medicine (IOM) report's assertion that the majority of errors result not from human recklessness but from failures in the health care system and believes the report reinforces the need to address all systems issues, including staffing though the report itself lacks important information on the relationship between system errors and appropriate staffing. In fact, ANA has voiced significant criticism of the report due to its woefully inadequate attention to the staffing component of this issue.

Several surveys of nurses during the past few years reveal that medication errors often result when there is inappropriate staffing. Inappropriate staffing may mean too few registered nurses, lack of appropriate training or orientation for an RN assigned to the unit or inappropriate use of unlicensed personnel. Adequate numbers of staff are necessary to reach a minimum level of quality patient care services. In 1994, ANA launched its Safety & Quality Initiative to investigate the impact of health care restructuring on the safety and quality of patient care and the nurses who provide that care. Central to this initiative is the development of Nursing Quality Indicators, the Nursing Report Card for Acute Care and the National Database of Nursing-Sensitive Quality Indicators.

However, the ANA supports many of the IOM study's recommendations, including the creation of a center for patient safety within the U.S. Department of Health and Human Services that would set national safety goals, track progress in meeting them and invest in research to learn more about preventing mistakes. The ANA also supports the IOM's call for a nationwide, mandatory reporting system under which health care systems would be responsible for reporting medical errors to state governments, Currently, about a third of all states have such a system in place. ANA would argue however that such a system of reporting and tracking adverse events must not only maintain data on when the errors are occurring, but include information on what organizational variables are responsible for the errors.

While also agreeing with the report's recommendation for regulating and accrediting bodies to make medical errors a key component of their evaluations, the ANA is concerned with the IOM's call for licensing and certifying bodies to implement periodic re-examinations of health care providers to address this issue. By including this component, the report contradicts its core concept of not focusing on individual culpability. ANA supports the goal of assuring nursing continued competency. Unfortunately however, the study ignores the significant ramifications of inadequate and inappropriate nurse staffing, which increases the potential for medical errors regardless of competency.

Ongoing evaluation and bench marking related to staffing are necessary elements in the provision of quality care. At a minimum, this should include collection and analysis of nursing-sensitive indicators (ANA/1997) and their correlation with other patient care trends. It has been shown that the quality of work life has an impact on the quality of care delivered. Therefore, on an ongoing basis, the following trends should be evaluated:

• work-related staff illness and injury rates
• turnover / vacancy rates
• overtime rates
• rate of use of supplemental staffing
• flexibility of human resource policies and benefit packages
• evidence of compliance with applicable federal, state and local regulations
• levels of nurse staff satisfaction

ANA has been working to pursue strategies that protect patients from preventable errors and that move organizations away from the traditional "search and destroy" missions that frequently follow serious health care errors. In addition to our Safety and Quality Initiative, ANA participated in the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. ANA is also a founding member of the National Coordinating Council for Medication Error Reporting and Prevention, and is actively involved the National Patient Safety Foundation sponsored by the American Medical Association and the Veterans Administration's National Patient Safety Partnership.

ANA believes nurses are the quality and safety monitors of health care. Nurses worry about systems that put providers and patients at risk. Today's environment demands that the nursing profession assert its powerful voice in the time-honored role as patient advocate by supporting public policies that protect consumers, enhance accountability for quality, and promote access to a full range of health care services. However, no system can succeed, no matter how brilliant, if there aren't qualified staff to implement it. Until health care administrators and the public focus on reducing system problems that contribute to clinical errors, shared accountability for systems improvement in health care can not be achieved. ANA will continue to increase hospitals' awareness of and participation in the national database of nursing-sensitive quality indicators. By working together, we can further document the link between nurse staffing and patient outcomes in order to make informed, data-driven decisions that will allow safe, quality patient care to be the norm in all patient care settings.

ANA appreciates the opportunity to participate in this discussion and we welcome the opportunity to work with you and other organizations to address this issue.

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