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In many discussions of patient safety, it is assumed that the workforce is up to the task—in training, competency, and numbers. In these formulations, a combination of the right processes, information technology, and culture is enough to ensure safe care.

However, as any frontline worker can tell you, neglecting issues of workforce sufficiency and competency omits an important part of the equation. For example, a nursing or physician staff that is overworked and demoralized will breed unsafe conditions, even if good communication, sound policies, and well-designed computer systems are in place.

In this chapter, we will discuss some key issues in workforce composition and organizational structure, including the nursing workforce, Rapid Response Teams, and trainee-related matters such as duty-hour restrictions and the so-called “July effect.” We’ll close with a discussion of the “second victim” phenomenon: the toll that errors take on caregivers themselves. In the next chapter, we’ll discuss issues of training and competency.


Much of our understanding of the interaction between workforce and patient outcomes and safety comes from studies of nursing, owing to a combination of pioneering research exploring these associations,18 a nursing shortage that emerged in the late 1990s in the United States, and effective advocacy by nursing organizations. Because most hospital nurses in the United States are salaried and employed by the hospitals, they have a strong incentive to advocate for sensible workloads. This is in contrast to physicians, who (again in the United States) are mostly self-employed (although hospital employment of physicians is increasing) and therefore calibrate their own workload.

Substantial data suggest that medical errors increase with higher ratios of patients to nurses. One study found that surgical patients had a 31% greater chance of dying in hospitals when nurses cared for more than seven patients, on average. For every additional patient added to a nurse's average workload, patient mortality rose 7%, and nursing burnout and dissatisfaction increased 23% and 15%, respectively. The authors estimated that 20,000 annual deaths in the United States could be attributed to inadequate nurse-to-patient ratios.1 One study, perhaps the most methodologically rigorous to date, confirmed the association between low nurse staffing and increased mortality. It also demonstrated that high rates of patient turnover were associated with mortality, even when average staffing was adequate.4 A systematic review of the evidence supports the safety benefits of increased nurse staffing ratios.9

Unfortunately, the demand for nurses cannot be met by the existing supply. Despite some easing of the U.S. nursing shortage, projected nursing workforce needs remains a concern. One study looked at the nursing shortages in each of the 50 states and assigned a letter grade for nursing workforce shortages. The number of states receiving a poor grade (D or F) was projected to increase from 5 states in 2009 to 30 states by ...

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