Why Nursing Care Should Be a Focus of the Patient Safety Movement

It’s July 1st.

For decades this day has marked the most meaningful transition in an American doctor’s career: the first day of residency training.  Today, over 30,000 freshly minted physicians are thrust into positions of power and responsibility, expected to be primary providers for often critically ill patients.

It’s as if it’s the final game of the season and half the roster is replaced by rookies.  The potential for medical error is at its peak this month, a phenomenon dubbed “the July effect” by both the medical community and lay press.  Although historically the medical literature has conflicted as to whether the influx of inexperienced physicians actually decreases patient safety, a recent meta-analysis suggests the July effect truly does lead to an uptick in patient mortality.  And if you ask Google, the message to patients is clear: don’t get sick in July.

My own July 1st experience began in a packed ICU.  Around mid-morning, I tried to order heparin drip for a patient with a pulmonary embolism.  But, perplexed and stumbling in a new electronic medical record, I ordered the heparin for the wrong patient – one with a massive gastrointestinal hemorrhage.  I’ll never forget the nurse who caught my error and graciously corrected my potentially fatal mistake.  I still feel as I’m sure the patient would be if he had any idea of what happened, forever indebted to her.

So instead of another discussion about how July residents make hospitals less safe for patients, let’s turn our attention to the power of nurses in maintaining the quality of care patients expect when they’re admitted to the hospital.  Because if there’s any time we need nurses to help keep sick patients safe, it’s July.


The medical literature has long supported the logical hypothesis that optimal nursing environments improve patient outcomes.  The bulk of this literature has focused on nurse-to-patient ratios, a metric of great concern to physicians, policymakers, and patients.   A 2002 study among hospitals in Pennsylvania estimated that for each additional patient added to the workload of a registered nurse, the risk of death following common surgical procedures was 7%.  Perhaps even more striking, they also found that the risk of death was over 30% higher in hospitals where nurse workloads averaged 8 patients or more when compared to those where nurses cared for a maximum of 4 patients.

In the intensive care setting, the effect of nursing ratios on patient safety is even more dramatic.  A 2007 study found that adding 1 additional RN to an average ICU not only decreased the odds of all-cause mortality by 9% but also cut the risk of cardiac arrest by 30% and respiratory failure by a whopping 60%.

Aside from staffing, nursing education level also appears to affect patient outcomes.  One study, after examining 168 hospitals, found that patients at hospitals where a larger portion of registered nurses had baccalaureate degrees – as opposed to hospital diplomas or associate degrees – had significantly lower postoperative mortality rates compared to those hospitals who employed fewer RNs with bachelor’s degrees.  It’s easy to understand why.  Studies have shown that baccalaureate-prepared nurses are more likely to demonstrate professional behaviors critical to patient safety, like problem-solving, performance of complex functions, and effective communication.


Clearly, increasing both the quality and quantity of nurses has a decidedly positive impact on patient-centered outcomes.  But as the cost of health care careens out of control – especially in the American system I practice in – we must consider not just the impact but the value of potential nursing improvement interventions.  Although prior articles have questioned whether creating better nursing environments is cost effective, a study in JAMA Surgery last month put the issue to rest.  The researchers, after confirming a significant decrease in mortality with better nursing ratios, found that there was essentially no difference in cost per patient between different staffing models, thus providing support for the logical theory that improving the nursing environment is, in fact, a high-value endeavor.

In the effort to keep hospitalized patients safe, focusing on strategies to improve nursing education and staffing should form a cornerstone of the patient safety movement.  And to patients that do get sick in July, thank your nurses.  They probably helped your doctor even more than you realize.


By Nicole Van Groningen