Clinical TopicsEducationPatient SafetyPractice MattersWorkplace Management

Déjà vu all over again


Sometimes being older than dirt pays off. Even the most junior gerontologic specialist knows that the last thing to go is a person’s long-term memory. Both of these statements fit nicely into this month’s column. The thing about being ancient is that you were there when so many things were tried and retried—and are now being tried again. I’m referring to the joint evils of understaffing and substituting lesser-prepared staff for better-prepared staff.

Some people simply can’t learn from the past—even the fairly recent and painful past. What clued me in (besides the fact that some hospitals are firing RNs and replacing them with LPNs) are the latest hospital safety scores from the Leapfrog Group, released in late October 2013. The scores, which reflect rates of errors and infections (indicators of safe practice), show a troubling increase in the number of hospitals earning the lowest score, an F. Here are the key findings from the Leapfrog report:

  • On average, hospitals’ performance didn’t improve on the measures included in the score—except for greater adoption of computerized physician order entry. Expanded adoption of this technology suggests federal policy efforts to improve hospital technology have seen some success.
  • Of the 2,539 general hospitals that received a safety score, 813 earned an A, 661 earned a B, 893 earned a C, 150 earned a D, and 22 earned an F (six more than in May 2013.)

Now for a brief trip down memory lane: In a cross-sectional analysis of outcomes data (published in 2003) for 232,342 general, orthopedic, and vascular surgery patients who’d been discharged, researchers linked staff nurses’ educational level to patient mortality indices. After adjusting for patient and hospital structural characteristics, they found that a 10% increase in the proportion of nurses holding a bachelor’s degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and the odds of failure to rescue.

This reminds me of a story a veteran emergency department (ED) nurse told me about a patient who came to the ED with both ears severely burned. When taking his history, she asked him what happened. He explained, “My wife was ironing clothes behind my chair while I was watching TV. She put the iron down next to the phone, and when the phone rang I answered the iron.”

“Wow, that’s terrible!” the nurse responded. “But what happened to your other ear?”

“Well,” he said, “right afterward, the phone rang again!” (If your ears are burning, you know who I’m talking about!)

Like that ED patient, hospitals are making the same mistake again—and getting burned again. They did it with RNs in the 1980s, when all types of errors increased, and again in the late 1990s (as discussed in the 1999 Institute of Medicine Report To Err is Human: Building a Safer Health System). Now they’re headed toward yet another burning.

A 2011 meta-analysis of nurse staffing and patient morbidity found a significant link between increased mortality and exposure to unit shifts during which RN staffing was 8 hours or more below the target level.

What makes hospitals think they won’t get burned this time around? Doing the same thing over and over produces the same result.

Leah Curtin, RN, ScD(h), FAAN

Executive Editor, Professional Outreach

American Nurse Today

Selected references

Aiken LH, Clarke SP, Cheung RB, Sloane, DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12):1617-23.

Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999.

Leapfrog Group. Hospital Errors are the third leading cause of death in U.S., and new hospital safety scores show improvements are too slow. Accessed October 31, 2013.

Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364(11):1037-45.


  • I have some responses to each of these respondents: 1) Leah Binder — I am flattered you read the article. Thank you and Leapfrog for the work you are doing. 2) Joanne, I agree we must cut costs, but poor staffing costs more than it saves in terms of both human suffering and money. 3)raleman is correct about the Meta-analysis of nurse staffing and related variables-Need to update it again but yesterday or today, conclusion’s the same.4) Carol Ann,you know more about staffing than anyone!

  • Leah, a long time connecting. Shame on me!! This noon I read your article; De’ja vu all over again. Couldn’t have said it better. There a re a few CEO’s calling wanting help with the mess because volume and reimbursement in dropping. Not fun to be in acute care at this time.

  • raleman@yahoo.xom
    January 29, 2014 4:11 am

    You did nor cite yourself when writing this article, but I am sure I remember a meta-analysis of research on nurse staffing. As I recall, it appeared in the Online Journal of Issues in Nursing. True? And weren’t your conclusions much the same?

  • With Medicare, Medicaid and now Obamacare cutting reimbursements, cuts have to be made somewhere!

  • Patient safety is truly a nursing issue. We hope nurses join us in advocating for full transparency of safety data–because their priorities are right for their patients.–Leah Binder, President & CEO, The Leapfrog Group

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