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| Executive Summary | |
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| Nursing: Inseparably Linked to Patient Safety | |
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| Thousands of Health Care Errors | |
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| Why Health Care Errors Occur | |
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| The Central Role of Nurses in Patient Safety | |
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| Patient Safety Risk Factors in Nurses' Work and Work Environments | |
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| Threats to Patient Safety Posed by Work Environment Factors | |
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| Transforming Nurses' Work Environments: Essential to Patient Safety | |
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| References | |
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| A Framework for Building Patient Safety Defenses into Nurses' Work Environments | |
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| Building on To Err Is Human and Crossing the Quality Chasm | |
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| The Need for Bundles of Multiple, Mutually Reinforcing Patient Safety Defenses | |
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| An Evidence-Based Model for Safety Defenses in Work Environments | |
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| Unique Features of Health Care That Have Implications for Patient Safety Defenses | |
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| References | |
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| Nurses Caring for Patients: Who They Are, Where They Work, and What They Do | |
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| Who Is Doing the Work of Nursing? | |
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| Where Nurses Work | |
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| What Nurses Do | |
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| References | |
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| Transformational Leadership and Evidence-Based Management | |
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| Transformational Leadership: The Essential Precursor | |
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| Five Essential Management Practices | |
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| Uneven Application of Evidence-Based Management Practices in Nurses' Work Environments | |
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| Models of Evidence-Based Management in Nurses' Work Environments | |
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| Use of Evidence-Based Management Collaboratives to Stimulate Further Uptake | |
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| References | |
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| Maximizing Workforce Capability | |
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| Promoting Safe Staffing Levels | |
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| Supporting Knowledge and Skill Acquisition and Clinical Decision Making | |
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| Fostering Interdisciplinary Collaboration | |
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| References | |
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| Work and Workspace Design to Prevent and Mitigate Errors | |
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| Design of Work Hours | |
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| Design of Work Processes and Workspaces | |
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| References | |
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| Creating and Sustaining a Culture of Safety | |
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| Essential Elements of an Effective Safety Culture | |
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| Need for a Long-Term Commitment to Create a Culture of Safety | |
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| Barriers to Effective Safety Cultures from Nursing and External Sources | |
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| Progress in Creating Cultures of Safety | |
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| Need for All HCOs to Measure Their Progress in Creating Cultures of Safety | |
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| Recommendations | |
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| References | |
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| Implementation Considerations and Needed Research | |
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| Health Care Organizations and Other Parties Should Not Wait to Act | |
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| Multiple, Mutually Reinforcing Safeguards Are Needed | |
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| Benefits in Addition to Patient Safety Are Likely | |
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| Additional Research Is Required to Further Increase Patient Safety | |
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| Recommendation | |
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| References | |
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| Appendixes | |
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| Committee Membership and Study Approach | |
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| Interdisciplinary Collaboration, Team Functioning, and Patient Safety | |
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| Work Hour Regulation in Safety-Sensitive Industries | |
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| Index | |