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 efficient computers are in place.
In this chapter, I 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.” I'll close with a discussion of the “second victim” phenomenon: the toll that errors take on caregivers themselves. In the next chapter, I'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. The combination of pioneering research exploring these associations,1–5 a U.S. nursing shortage that emerged in the late 1990s, 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; contrast this to physicians, most of whom are self-employed and therefore calibrate their own workload) has created this focus.
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, on average, a nurse cared for more than seven patients. 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 A recent study, the most methodologically rigorous to date, confirmed the association between low nurse staffing and increased mortality, further demonstrating that high rates of patient turnover were also associated with mortality even when average staffing was adequate.5
Unfortunately, these studies point to a demand for nurses that cannot be met by the existing supply. Despite some easing of the U.S. nursing shortage, in 2012 the demand for nurses continued to exceed supply by over 100,000; this mismatch was projected to grow (to a shortfall of more than 250,000 registered nurses) with the aging of the American population.6 While more young people have entered the nursing profession in recent years, nearly one million of the nation's nurses (nearly one in four) are over age 50, adding to the challenge.
Efforts to address the nursing shortage have centered on improved pay, benefits, and working conditions. In the future, technology could play ...