IN THE SEPTEMBER issue of Nursing2005, we asked you to respond to 40 questions or statements pertaining to patient safety in health care facilities. The response far exceeded our expectations: 4,826 nurses throughout the United States and Canada participated (see Respondent snapshot). Besides answering the survey items, many nurses provided additional handwritten comments about safety issues in their facility.

Our goal in conducting this survey was to explore nurses' perceptions about patient safety, including their views on falls, medication errors, and other preventable adverse events related to health care. We also wanted to learn how well facilities and nurses adhere to current safety standards and whether nurses believe their own facilities are implementing and enforcing programs that support a culture of safety in daily practice.

As you'll see in this report, we discovered some encouraging trends as well as much room for improvement. For example, over 80% of respondents said they believe that bedside nurses in their facility contribute to a culture of safety. But when asked whether their facilities take a nonpunitive approach to error reporting, many were ambivalent. "A combination of both," one nurse wrote. "We're trying to move away from blaming, but it takes time to change a cultural mind-set."

Other nurses voiced frustration with chronic understaffing as an impediment to safe nursing care. Said one respondent, "It's a joke to listen to management preach about patient safety and ignore the obvious: too many patients to one nurse."

In the following pages, we'll examine the answers to each survey item and discuss their implications for nursing practice and patient safety. Please note that figures have been rounded and that not all respondents answered every question. Study results were based on a convenience nonprobability sample.

Respondents were asked to respond to many survey questions by marking a 1-to-5 scale. We've reproduced the scales where appropriate and indicated the mean score for all respondents.

Question 1: I believe most errors are related to

Discussion: Although human, system, and communication failures all contribute to errors, respondents identified poor communication as the most significant factor. Because communications breakdowns lead to errors, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made improving communication across health care organizations one of its National Patient Safety Goals.

Patient-safety experts say the best way to prevent errors is to improve the systems that guide health care practices. System failures that contribute to medication errors include poorly developed prescription, transcription, delivery, and administration protocols and a lack of checks and balances. When built into the system, automatic checks and balances help decrease human failures and alert clinicians to errors so they can be corrected before they reach the patient. For example, computer systems can be programmed to alert prescribers to unsafe dosages or potential interactions with another drug the patient is taking. Computerized prescriber order entry also eliminates errors based on bad handwriting.

Among survey respondents, students, younger nurses, and nurses with less than 5 years' experience were most likely to identify human failures as the most important source of errors. This suggests that nurses may need more education about the importance of developing medication delivery systems and other processes that reduce the risk of human error. Failing to correct communication and system failures increases the likelihood of human failures and contributes to a punitive or blaming atmosphere, which discourages nurses from reporting errors or near misses.

Question 2: Sharing experiences regarding safety issues with colleagues helps prevent errors.

Discussion: Ninety-four percent of respondents circled 4 or 5 on the scale, indicating agreement with this statement. Nurses in pediatric and ambulatory care settings scored especially high on this item (mean, 4.7), indicating a strong belief in the value of sharing information.

The sharing of experiences educates nurses in a "lessons learned" manner by highlighting how an error evolved and how it could have been prevented. As we'll discuss in more detail shortly, nurses don't feel comfortable sharing information about mistakes with others if they work in an environment that blames individuals for errors.

Question 3: I believe the bedside/primary nurses at my facility contribute to the culture of patient safety.

Discussion: Eighty-three percent of respondents said they agree or strongly agree that bedside/primary nurses contribute to the culture of safety at their facility. Because nurses are involved in patient care at all levels, they must participate in patient-safety initiatives. Most nurses responding to our survey agree that this is happening.

Question 4: I believe errors should be disclosed to patients.

Discussion: Research has shown that disclosing errors to patients promotes professional integrity and decreases liability to the nurse and the health care organization. Fifty-seven percent of respondents said they agree or strongly agree with disclosure of errors to patients, and only 12% said they disagree or strongly disagree. Yet only 48% reported that their facility has a policy for disclosing errors (see question 32 for more discussion on this issue). Nurses who scored significantly above the mean on this question included those with BSN or MSN degrees, those older than age 40, and those with more than 21 years' experience. Nurses with specialty certifications scored significantly higher on this item than those without certification. Nurses scoring significantly below the mean included LPNs and PhDs.

Question 5: I was well educated about patient-safety issues in nursing school.

Discussion: Overall, only 42% of respondents think they were well educated about patient-safety issues in nursing school. Respondents above age 41 and those with more than 16 years' experience responded well below the mean for all nurses. In contrast, younger, less experienced nurses responded well above the mean. Among respondents of all educational levels, nursing students were most likely to respond above the mean. These findings suggest that nursing schools are offering more education on patient safety today than in the past.

Question 6: I'm well informed about patient-safety issues affecting my practice.

Discussion: Eighty-five percent of respondents think they're well informed about patient-safety issues affecting their practice. More than half of these respondents who felt well informed also reported participating in regular interdisciplinary rounds on patients (see question 26), and 85% of them reported that their facilities have a patient-safety committee (see question 21). Significantly more nurses who reported that their facilities have a patient-safety committee felt well informed about patient-safety issues.

These results indicate that progress is being made in educating nurses about safety issues. Ideally, however, all facilities should have patient-safety committees with nurses serving as regular members.

Question 7: I'm familiar with early response or rapid response teams.

Discussion: Eighty-five percent of respondents reported they've heard of or are very familiar with early or rapid response teams. Unlike traditional code teams, rapid response teams intervene when a patient's condition begins to deteriorate, before he experiences respiratory or cardiac arrest. Research shows that deploying these teams saves lives.

Deploying rapid response teams is one of the six strategies promoted by the Institute for Healthcare Improvement (IHI) in its campaign to save or extend 100,000 lives by June 2006. (See "Best-Practice Interventions: Suppressing the Scourge of AMI" on page 36 for this month's article in Nursing2006's six-part series on the IHI's safety campaign.)

Question 8: I'm familiar with the Institute of Medicine reportTo Err Is Human.

Discussion: Sixty-three percent of respondents said they'd heard of this landmark report or were very familiar with it. Published in 1999, To Err Is Human: Building a Safer Health System suggested that as many as 98,000 people may die annually because of medical errors. The original and follow-up reports from the Institute of Medicine (IOM) were well publicized in the lay press and drew public attention to the importance of a national health care initiative to promote patient safety.

Respondents ages 41 to 65 and those with 21 or more years of experience answered above the mean for this question. Nurses with AD, BSN, and MSN degrees scored significantly higher than LPNs, RN diploma nurses, and PhDs. Nurses working in hospitals scored higher than those in other work settings. Nurses working in geriatrics scored significantly lower than those in other clinical areas.

Interestingly, students seemed largely unfamiliar with the IOM report, scoring only 2.3 on the scale, although other data indicate increased emphasis on patient safety in nursing schools. One explanation may be that nursing education focuses on practical safety issues rather than historical background.

Question 9: I'm familiar with the National Patient Safety Goals issued by the Joint Commission on Accreditation of Healthcare Organizations.

Discussion: In contrast to the question above, 92% of respondents answered that they'd heard of the JCAHO goals or were very familiar with them. The higher score indicates that health care organizations are educating their staff about the National Patient Safety Goals. Students or those with less than 1 year of experience were the only group of respondents to fall below the total mean, suggesting that nursing schools need to incorporate information regarding the National Patient Safety Goals in their curricula.

Question 10: I learn about patient-safety issues in these ways. (Check all that apply.)

Discussion: Staff meetings and journal articles were the most cited means of communication. When conducted regularly, staff meetings provide a good forum for dissemination and discussion.

Among the 8% who checked "other," many respondents specified safety or educational committee meetings as a source of information about patient-safety issues. One respondent mentioned "safety huddles" at each shift change.

Question 11: I feel comfortable reporting potential patient-safety hazards.

Discussion: Eighty-nine percent of respondents reported that they feel comfortable or very comfortable reporting potential patient-safety hazards. Significantly more ofrespondents who feel comfortable reporting potential hazards also said:

* my facility's attitude toward error reporting is objective/understanding/constructive (see question 14)

* my facility promotes a culture of patient safety (see question 39).

Nurses who are older, have more years of experience, and who have a BSN or MSN indicated that they're more comfortable reporting potential patient-safety hazards. Those working in rehabilitation and home health care are more comfortable reporting potential hazards than nurses in other work settings.

Question 12: I'm familiar with my facility's policy on adverse event reporting.

Discussion: Ninety-one percent of respondents said that they're familiar or very familiar with their facility's policy on adverse event reporting. On this question, age and experience were the most important determinants: Nurses with 5 years' experience or less and those below age 30 scored below the mean.

Question 13: Nurses in my facility receive adequate staff education about reporting adverse incidents.

Discussion: Most respondents think they receive enough education about reporting adverse incidents. Nurses in facilities with a patient-safety committee were significantly more likely to feel well informed about safety issues. However, nurses working in emergency departments (EDs), long-term care, offices, and prisons reported feeling less well informed than their counterparts in other practice settings.

Among respondents who felt they receive adequate education from their facilities, 69% reported that error reports are reviewed for educational purposes (see question 31).

Question 14: When an error is reported at my facility, the response is

Discussion: Research and current literature encourage health care organizations to develop a culture that takes a nonpunitive, objective, understanding, and constructive approach to error reporting. This encourages reporting so flaws in processes and systems can be identified and fixed. A punitive atmosphere discourages reporting, allowing system flaws to remain concealed and perpetuating errors.

Although nearly three-quarters of respondents described their facility's atmosphere as nonpunitive, a large minority (26%) checked punitive or "other." Many nurses checking "other" felt that their facility's attitude is uneven or inconsistent. Here's a sampling:

* "Administration is supportive and teaching, but other staff members are punitive."

* "Depends on the situation. Med errors are punitive and blaming; falls are objective."

* "It depends on the department manager. I'm lucky to have a manager who usually looks at things as a learning experience."

* "Our policy is communicated as objective and understanding...but in reality behind closed doors, it's more blaming."

Among work settings, long-term-care settings were significantly more punitive than hospitals, home health care, and ambulatory care.

Question 15: At my facility, incident reports are received by (check all that apply)

Discussion: Many respondents checking "other" identified quality assurance personnel. Some named pharmacists or physicians, and a few named facility CEOs or other members of top management.

Several nurses mentioned computerized incident reporting systems. Reported one nurse, "We just implemented an online process, which can be confidential and goes directly to risk management. I'm hopeful that this will prevent cover-ups."

Ensuring that incident reports are forwarded to appropriate personnel is essential to understanding and correcting the root causes of adverse events. A risk manager should review all reports and oversee the collection and analysis of data to identify trends.

Question 16: I usually give report

Discussion: Direct, face-to-face reporting supports the continuity of care and encourages good communication among health care team members. Written or tape-recorded reports don't allow nurses to readily exchange information or answer questions, and a nurse coming on duty may be reluctant to call a colleague for clarification after she's left work.

Face-to-face reporting is most common in these clinical areas: the ED, operating room (OR)/perioperative, intensive care unit (ICU), and pediatrics. Medical/surgical, geriatrics, and rehabilitation reported the lowest use of face-to-face reporting.

Our data indicate that Canadian nurses are less likely to give face-to-face reports, as follows: face-to-face, 48%; written, 31%; tape recording, 21%.

Question 17: I make bedside rounds with another nurse during or after report.

Discussion: Making bedside rounds with another nurse during or after report provides for a double-check system, supports continuity of care, and enhances patient safety. So it's disappointing that only 24% of respondents said they perform bedside rounds with another nurse during or after report. Another 23% reported that they do so occasionally. Among medical/surgical nurses, 49% said they never make bedside rounds. Clinical areas with the best scores on this question were ICU, OR/perioperative, pediatrics, and ED. More than 50% of respondents from each of these areas said they made bedside rounds with another nurse at least occasionally.

Question 18: I identify each patient using at least two patient identifiers (such as ID band and medical record number) before performing interventions, including medication administration.

Discussion: Only 56% of respondents said they always use two patient identifiers, as recommended by the JCAHO. In a written comment, one nursing administrator said, "I'm frustrated that bedside nurses don't always want to change behaviors based on patient-safety literature.... Getting nurses to check two identifiers is like pulling teeth; they think they know the patient well enough after the initial assessment."

Medical/surgical nurses in hospital settings scored the highest on this question; nurses working in geriatrics and long-term care scored the lowest. Nurses most likely to report using two identifiers were older nurses, those with more years of experience, and those with a BSN, MSN, or specialty certification.

Because nurses in long-term-care facilities tend to have longer contact with familiar patients, they may feel that using two identifiers is unnecessary-a risky assumption. These nurses may also have specific challenges related to their patients' advancing age; for example, a patient's inability to identify himself or state his name. To address these problems, many long-term-care facilities create special patient-identification aids, such as a book containing patients' names and photos, which nurses can use to check against a patient's armband.

Question 19: I double-check critical medications (such as heparin and vasoactive medications) with another professional before giving them.

Discussion: Because errors involving high-risk intravenous (I.V.) medications can be especially devastating, double-checking dosages before giving them is becoming the standard of care. Barely more than three-quarters (77%) of respondents said they perform such checks. Nurses who work in the OR and pediatrics responded well above the mean; nurses working in geriatrics and long-term care scored lowest. However, low scores in these areas may reflect the fact that critical drugs aren't commonly given in these settings.

One disturbing finding is that ICU nurses, who routinely administer high-risk I.V. drugs, scored below the mean on this question (3.9). Nurses in ICU settings may need more education and reinforcement on the importance of performing double checks for high-risk drugs.

Question 20: My facility utilizes the following technology. (Check all that apply.)

Discussion: Recent research has shown that when properly used, technologies like these can reduce adverse events by putting into place more checks and balances. Medication bar coding and computerized prescriber order entry systems are two especially promising technologies, but neither is widely used according to this survey. However, many respondents noted that in their facility, plans to introduce or implement new technologies are under way.

Nurses need to participate in committees investigating new technologies and advocate for their use to create safer environments.

Question 21: My facility has a patient-safety committee.

Discussion: Nurses working in geriatric clinical settings and long-term-care facilities were less likely to report a patient-safety committee (75% and 71% respectively).

Question 22: My facility has a fall prevention program.

Discussion: Research and literature support that fall prevention programs can help to prevent injury from falls.

Question 23: My facility's fall prevention program is effective.

Discussion: As the previous question showed, most respondents reported a fall prevention program in their facility. But only 55% of respondents said they think their facility's program is effective, and 37% of respondents circled the scale's neutral 3. The results indicate that many nurses either don't believe their facility's is effective or don't know. (Some respondents may have marked the neutral choice because a fall prevention program isn't applicable in their setting.)

To protect patients, a fall prevention program should include an initial assessment of fall risk, appropriate interventions to reduce the risk (such as use of safety beds or bed alarms), frequent toileting if indicated, and reevaluation of all patients at regular intervals. Staff needs ongoing education, feedback, and support from management to ensure that the program is and continues to be effective. One nurse commented, "We could really use more information on effective fall prevention, including alternatives to restraints."

The payoff in terms of reduced patient injuries can be significant. One nurse commented, "Our program aims to identify those at risk on day one and then to utilize all methods possible to reduce or prevent falls. Falls will still occur, but we have reduced the number of injuries by employing such things as pressure-sensitive seat alarms, scoop mattresses, low and low-low beds, and mats at the bedside." Another nurse said, "Almost all patients in my unit have a risk for fall or other safety concerns, such as pulling out tubes. We have activity companions available to 'sit' with higher-risk patients. We have our share of falls, but rarely is a patient injured from a fall because of the steps we take and are encouraged to take."

Question 24: Multidisciplinary team members in my work area communicate well.

Discussion: Only 54% of respondents believe that multidisciplinary team members communicate well in their work area. Another 32% of respondents were neutral (circling 3 on the scale). However, the scores on this question were significantly higher among nurses who work in facilities that have multidisciplinary rounds, indicating that these rounds improve team communication.

Question 25: At my facility, nurses mix high-risk drugs, such as vasoactive I.V. drugs.

Discussion: Overall, 21% reported that they mix high-risk drugs, which is considered a dangerous practice.But the percentages were much higher among nurses working in the ED (48%) and ICU (39%).

To decrease medication errors, many facilities have put in place policies that prohibit nurses from mixing any medications except in emergencies (such as during a code). These policies work toward compliance with the JCAHO national patient safety goal to improve the safe use of medications. Nurses and pharmacists should periodically review high-risk drugs that nurses mix in emergencies and look for ways to minimize this practice; for example, by substituting a premixed solution for a drug that nurses currently mix. Unit-based pharmacists and 24-hour pharmacy services reduce or eliminate the need for nurses to prepare high-risk medications.

Question 26: We have regular interdisciplinary rounds on patients.

Discussion: Participating in regular interdisciplinary rounds correlates well with good communication among multidisciplinary team members. Research has shown that interdisciplinary rounds improve communication, enhance continuity of care, and empower nurses.

Question 27: My facility encourages nurses to report actual patient-safety hazards.

Discussion: Reporting and monitoring patient-safety hazards is required by the JCAHO and departments of health. Facilities that encourage reporting hazards help improve safety by identifying areas of high occurrence/high risk.

Question 28: My facility encourages nurses to reportpotentialpatient-safety hazards.

Discussion: A "near miss"-an error that was caught before it reached the patient-is a good example of a potential patient-safety hazard. Reporting potential as well as actual patient-safety hazards provides a more complete picture of system shortcomings that contribute to adverse events. Most respondents who reported that their facility promotes a culture of patient safety (see question 39) also reported that their facility encourages reporting of potential safety hazards.

Technology can also be employed to enhance potential error reporting. One respondent reported, "We went to a computerized med-error reporting system that is an icon on every computer at this facility. We went from around 10 near misses reported per quarter to over 100 by making it simple and easy for staff."

Question 29: My facility uses error reporting to enhance patient safety.

Discussion: Ninety-five percent of respondents who reported that their facility uses error reporting to enhance patient safety also reported that their facility's approach to error reporting is objective/understanding/constructive (see question 14). Moving away from a punitive or blaming attitude helps create a learning environment. Processes such as Root Cause Analysis (performed after an adverse event to determine cause) and Failure Modes and Effects Analysis (performed to identify and eliminate errors before they occur) can help explain why and how an error occurred and suggest strategies for preventing future errors.

Question 30: Patient-safety concerns are addressed at my facility.

Discussion: Eighty percent of respondents reported they agree or strongly agree that patient-safety concerns are addressed at their facility. Emergency department nurses were less likely to agree with this statement than nurses from other clinical settings.

Standards set by the JCAHO and departments of health require that health care facilities have a formal mechanism for addressing patient-safety concerns-yet 20% of our respondents don't think their facility addresses patient-safety concerns adequately or at all.

Question 31: At my facility, we review errors for educational purposes (no names, just the facts).

Discussion: Fifty-nine percent of respondents reported that their facility reviews errors for educational purposes. Results didn't vary according to clinical area, work setting, or region. Many nurses may simply be unaware of what kind of review process occurs in their facility.

Question 32: My facility has a policy of disclosing errors to patients.

Discussion: Nurses who work in hospitals and pediatric or rehabilitation clinical settings were most likely to report a policy of error disclosure to patients. Organizations such as the JCAHO and the Agency for Healthcare Research and Quality recommend that facilities have a policy in place to guide the practice of disclosing errors to patients and family members, and some states have enacted legislation guiding disclosure of serious adverse events.

How, when, and why to disclose errors to patients remains somewhat controversial, but research suggests that patients who've been harmed by an error are more likely to sue if they believe they've been deceived or treated dishonestly. All facilities should have policies and procedures in place to help nurses and other staff deal with error disclosure consistently and with integrity.

Question 33: The nurse staffing level in my practice area promotes patient safety.

Discussion: Although 53% of respondents agreed with this statement, 26% were neutral, 12% disagreed, and 9% disagreed strongly. Clinical practice areas and work settings with significantly low mean scores include the ED, geriatrics, and long-term care. Geographically, the mid-Atlantic region of the United States and Canada scored below the mean on this question.

Staffing issues are a recurring theme in this survey, and many respondents had plenty to say.

* "Units are run so lean that people don't have time to read or attend inservices about safety issues."

* "It seems that whatever positive steps the facility takes to ensure patient safety (such as automated drug dispensers, smart pumps, fall prevention programs, and bar coding) are mostly negated by staff reduction leading to higher patient ratios."

* "Plain and simple, if the staffing is appropriate not only on the basis of numbers but also acuity, patients would be much more safe."

* "You may hear the 'short staffing' issue come up, but in all honesty, it's the support systems for RNs that are being cut away-the assistive personnel, unit clerks, utility workers, and other staff considered 'nonessential' in a budget crunch. The RN has a much heavier workload and no helpers."

Discussion: Forty-one percent of respondents reported their facility employs agency and temporary nurses regularly or fairly regularly, 15% were neutral, and 44% indicated their facilities rarely or never use agency or temporary nurses. More research is needed to determine the impact of temporary staffing on patient safety.

Question 35: Staff in my facility routinely work more than 12 hours at a time.

Discussion: Only 22% of respondents agreed with this statement, 21% were neutral, and 58% disagreed or strongly disagreed. Canadian nurses had the lowest mean score (2.3) among all geographic regions. In the United States, regions with the lowest means were the Pacific, West North Central, and East North Central states; the highest means were reported in the mid-Atlantic and East South Central states.

Working long hours, especially more than 12 hoursa day, increases risks for patients and nurses alike. "I have numerous concerns about patient safety and 12-hour shifts," one nurse wrote. "Most of the nurses I work with say the last 4 hours of a 12-hour shift are wasted; they're brain-dead and have a hard time keeping up with duties and remembering what they have to do."

Research supports this nurse's observation. According to Rogers, et al. (see Selected references), the risk of errors rises significantly when nurses work longer than 12 hours, when they work overtime, and when they work more than 40 hours a week. Rogers' study indicated that 75% of shifts scheduled to last 12 hours actually exceeded 12 hours.

Our survey data suggest that 22% of facilities still expect nurses to routinely work more than 12 hours at a time. Rogers recommends cutting back on the use of 12-hour shifts and eliminating overtime on top of 12 hours entirely.

Question 36: When a crisis arises or a lot of work needs to be done quickly, I can depend on my peers to help.

Discussion: Seventy-five percent of respondents said they can depend on peers to assist in a pinch. Teamwork enhances the culture of safety for patients and nurses and increases nurse job satisfaction.

Respondents from geriatric or long-term-care settings scored significantly below the mean on this question. This doesn't necessarily mean that they consider their peers less dependable; rather, it may signify that less staff is available to pitch in.

Question 37: Errors have led to changes that improve patient safety in my practice setting.

Discussion: Seventy-four percent of respondents reported that errors in their facility led to changes that improved patient safety, such as multidisciplinary safety rounds.

Question 38: Staff nurses are encouraged to discuss patient-safety issues that may compromise patient care.

Discussion: Seventy-five percent of respondents reported they feel encouraged to discuss patient-safety issues that may compromise patient care. Encouraging staff nurses to discuss patient-safety issues promotes a nonpunitive work environment and a culture of safety.

Question 39: My facility promotes a culture of patient safety.

Discussion: Seventy-seven percent of respondents reported they believe their facility promotes a culture of patient safety. Over 90% of these respondents also said they're encouraged to discuss patient-safety issues that may compromise patient care. Overall, 18% of respondents were neutral on this question and 6% disagreed or strongly disagreed that their facility promotes a culture of safety.

A culture of safety means that actions and attitudes supporting patient safety are integral to everyday practice. Improving and maintaining safety is a top priority for all staff, and the health care facility's policies and procedures consistently support staff in this goal. Among nurses who said they're not encouraged to report patient-safety hazards (see question 27), the mean score for this question was significantly lower than the overall mean (2.7). In contrast, nurses reporting an objective, understanding, nonpunitive work environment (see question 14) scored above the mean (4.3).

Question 40: If I were a patient in my facility, I'd feel...

Discussion: Sixty-nine percent of respondents reported they'd feel safe if they were a patient in their facility, 23% were neutral, and 9% wouldn't feel safe. We found a significant correlation between how safe nurses would feel in their own facility and whether they believe their facility promotes a culture of safety. Those who strongly believe their facility promotes a culture of safety scored well above the mean (4.4) on this question. Even more significant, those who strongly disagree that their facility promotes a culture of safety scored only 1.7 on this question.

Figure. No caption available.

Building a culture of safety

Survey results indicate that although the change is far from complete, the health care culture is shifting from a punitive or blaming approach to error reporting to an objective, constructive, and educational approach. "I think the whole patient-safety culture is evolving," one respondent observed. "Now we have support from administration to make changes and improve the culture. Prior to this, it was only the nurses doing what they could among themselves."

Is creating a culture of safety really possible in today's hectic and fragmented health care environment? We believe it is. When everyone in the system is on board, a culture of safety can become a reality, as reported by one nurse in this handwritten comment: "My facility is constantly stressing the importance of safety. We're reminded that safety is first and that it's everyone's responsibility. It's expressed and demonstrated at every level and in every department in our facility that safety should be the focus-every day and everywhere."

Respondent snapshot

Who responded to our survey? Here's a brief profile.

* Age: Most respondents were between ages 41 and 65. The largest percentage (39%) fell into the 41-to-50 range. The second largest group of nurses (36%) ranged in age from 51 to 65.(N=4,776)

* Years of experience: Most respondents (56%) had more than 21 years' experience in nursing. The second largest group (25%) had 11 to 20 years' experience. (N=4,775 )

* Educational level: The largest proportion of respondents (40%) had an associate degree. Another 22% had a BSN/BS, and 19% reported a PhD or other doctoral degree. (N=4,762)

* Clinical setting: The most frequently reported clinical settings were medical/surgical (24%), ICU (16%), ED (7%), and geriatrics (6%). (N=4,414)

* Work setting: By far, most respondents (82%) worked in a hospital. The next two largest groups, at 5% each, worked in ambulatory care or long-term care. (N=4,743)

* Certification in a specialty: Nearly half (45%) reported certification in a specialty. (N=4,736)

* Geographic distribution: Most respondents lived in the United States, but 225 (5%) lived in Canada. (N=4,743)

SELECTED WEB SITES

Agency for Healthcare Research and Quality

Institute for Healthcare Improvement

Institute for Safe Medication Practices

Institute of Medicine

Joint Commission on the Accreditation of Healthcare Organizations

Accessed on April 5, 2006.

SELECTED REFERENCES

Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses, Committee on the Work Environment for Nurses and Patient Safety. Washington, D.C., The National Academies Press, 2004.

Institute of Medicine. To Err Is Human: Building a Better Health System, Committee on Quality of Health Care in America. Washington, D.C., The National Academies Press, 2000.

Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs. 23(4):22-41, July/August 2004.

Manno MS. Preventing adverse drug events. Nursing2006. 36(3):56-61, March 2006.

Manno MS, Hayes DD. Best-practice interventions: How drug reconciliation saves lives. Nursing2006. 36(3):63-64, March 2006.

Potter P, et al. An analysis of nurses' cognitive work: A new perspective for understanding medical errors. Advances in Patient Safety: From Research to Implementation, volume 1. AHRQ Publication No. 05-0021-1, February 2005.

Rangaraj R, et al. Making a case for organizational change in patient safety initiatives. Advances in Patient Safety: From Research to Implementation, volume 2. AHRQ Publication No. 05-0021-2, February 2005.

Rogers AE, et al. The working hours of hospital staff nurses and patient safety. Health Affairs. 23(4):202-210, July/August 2004.

Savitz LA, et al. Quality indicators sensitive to nurse staffing in acute care settings. Advances in Patient Safety: From Research to Implementation, volume 4. AHRQ Publication No. 05-0021-4, February 2005.

Scholle CC, Mininni NC. Best-practice interventions: How a rapid response team saves lives. Nursing2006. 36(1):36-40, January 2006.