nursing, operational failures, patient safety



  1. Riman, Kathryn A.
  2. Harrison, Jordan M.
  3. Sloane, Douglas M.
  4. McHugh, Matthew D.


Background: Operational failures, defined as the inability of the work system to reliably provide information, services, and supplies needed when, where, and to who, are a pervasive problem in U.S. hospitals that disrupt nurses' ability to provide safe and effective care.


Objectives: We examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes (e.g., burnout and job satisfaction) and whether differences in hospital work environments explained the relationship.


Methods: We conducted a cross-sectional analysis using population-based survey data from 11,709 registered nurses in 415 hospitals who participated in the RN4CAST-US nurse survey (2015-2016) and the 2016 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The RN4CAST-US nurse survey focused on hospital quality and safety, job outcomes, and hospital work environments. The HCAHPS survey collected publicly reported patient data on their satisfaction with their care. Operational failures were evaluated using an eight-item composite measure that assessed missing supplies, orders, medication, missing/wrong patient diet, electronic documentation problems, insufficient staff, and time spent on workarounds and nonnursing tasks. Multilevel regression models were used to test the hypothesized relationships.


Results: Operational failures were associated with low patient satisfaction scores, poor quality and safety outcomes, and poor nurse job outcomes, and those associations were partly accounted for by hospital work environments.


Discussion: Operational failures prevent high-quality care and positive patient and nurse outcomes. Operational failures and the hospital work environment should be targeted simultaneously to maximize quality improvement efforts. Hospital leadership should work with frontline staff to identify and target the sources of operational failures in nursing units. Improvements to hospital work environments may reduce the occurrence of operational failures.