Objectives:

The purpose of this report is to compile and summarize existing evidence on the aspects of the working environment that impact patient safety. Five categories of working conditions were evaluated: workforce staffing, workflow design, personal/social issues, physical environment, and organizational factors.

Search Strategy:

Five bibliographic databases were searched; the databases were chosen to include citations from both the healthcare and non-healthcare literature. The databases included MEDLINE (with HealthSTAR), CINAHL, PsycINFO, EBSCO, and the Campbell Collaboration. Searches were conducted back to 1980 for MEDLINE and EBSCO, back to 1982 for CINAHL, and back to 1984 for PsycINFO. Additional studies were identified through hand searches of reference lists and selected tables of contents. Unpublished studies were identified through discussions with content experts.

Selection Criteria:

The criterion for inclusion in the literature review was that the article addressed patient safety or human performance, together with predetermined definitions of working conditions. Studies with no original data were excluded unless they were systematic literature reviews. Selection criteria were tested through dual reviews by a second investigator.

Data Collection and Analysis:

The articles included in the general literature review guided the definition of subcategories within the five main categories of working conditions. The quality of the evidence in individual studies was assessed through separate ratings of study design and execution. For each of the working-condition categories, six key questions were addressed to classify the nature of the evidence linking the working condition to aspects of patient safety.

Main Results:

The strongest evidence linking working conditions to aspects of patient safety is in the areas of workforce staffing and workflow design. Specific working conditions in these two categories affect both rates of medical errors and the incidence of patient outcomes related to patient safety. The patient outcomes affected include hospital-acquired infections, decubitis ulcers, and patient falls. There is not consistent evidence that working conditions affect the rates of preventable deaths in hospitals.

Conclusions:

The available evidence supports the recommendation that healthcare systems initiate demonstration projects and translational research to modify working conditions with the goal of improving patient safety. Specific areas in which such efforts are likely to be successful include: changes in nursing staffing, channeling high-risk technical procedures to high- volume physicians, avoidance of distractions in the healthcare workplace, and processes to improve information exchange between hospital and non-hospital settings. In addition, previous suggestive-but- inconclusive research indicates that limited investigations of workplace stress, lighting conditions, and organizational factors will clarify whether these additional working conditio ns affect patient safety.

Contents

• Preface
• Acknowledgments
• Summary
• 1. Introduction
  • Patient Safety and Medical Errors
  • Purpose and Scope of this Report
  • Definitions of Working Conditions
  • Analytic Framework
  • Key Questions
  • The Evidence-based Approach
  • Previous Systematic Reviews
• 2. Methodology
  • Literature Search and Selection Methods
  • Data Abstraction and Synthesis
• 3. Results
  • Evidence on the Effects of Working Conditions
  • Workforce Staffing
  • Nurse Staffing
  • Physician Workload
  • Professional Qualifications
  • Experience and Educational Qualifications
  • Temporal Factors
  • Workflow Design
  • Task Complexity
  • Monotony and Redundancy
  • Interruptions and Distractions
  • Transitions or “Hand-Offs” During Care
  • Computer Interface Design
  • Summary of Key Questions for Workflow Design
  • Personal/Social Working Conditions
  • Stress in the Hospital Work Environment
  • Dissatisfaction and Burnout
  • Physical Environment
  • Lighting and Color
  • Sound and Noise
  • Environmental Temperature
  • Organizational Factors
• 4. Conclusions
  • Evidence About the Effects of Healthcare Working Conditions
  • Key Question 1. Do Working Conditions Affect Patient Outcomes that are Related to Patient Safety?
  • Key Question 2. Do Working Conditions Affect the Rate of Medical Errors?
  • Key Question 3. Do Working Conditions Affect the Rate of Recognition of Medical Errors after they Occur?
  • Key Question 4. Do Working Conditions Affect the Probability that Adverse Events will Occur Following Detected or Undetected Medical Errors?
  • Key Question 5. Does the Complexity of the Plan of Care Affect Whether Working Conditions Affect Patient Outcomes that are Related to Patient Safety?
  • Key Question 6. Do Working Conditions Affect Measures of Service Quality in Industries Other than Health Care?
  • Clinical and Health Policy Implications of the Findings on the Effects of Healthcare Working Conditions
• 5. Future Research
• Evidence Tables
• Bibliography
• Appendix A: Research Team, Expert Panel, Technical Advisory Panel, and Peer Reviewers
• Appendix B: Search Strategies by Working Condition and for the Campbell Collaboration Database
• Appendix C: Search Results
• Appendix D: Data Abstraciton Guidelines
• References

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Drs Hickham, Schuldheis, and Helfand are affiliated with the VA Medical Center, Portland, Oregon. Dr Feldstein is also affiliated with the Kaiser Permanente Center for Health Research, Portland, Oregon.

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.¹ Contract Number: 290-97-0018,, Task Order No. 10. Prepared by: Oregon Health & Science University Evidence-based Practice Center, Portland, Oregon.

Suggested citation:

Hickam DH, Severance S, Feldstein A, et al. The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment Number 74. (Prepared by Oregon Health & Science University under Contract No. 290-97-0018.) AHRQ Publication No. 03-E??? Rockville, MD: Agency for Healthcare Research and Quality. April 2003.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

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