Designing a Culture of Safety: The Role of the RN in Patient Safety

The safety of patients in the healthcare system is reaching a critical level of concern, both for healthcare workers and patients. Patient safety is a vital component in the healthcare process and is essential in quality nursing care. However, because of an over-stressed system, increases in the need for quality healthcare, rising costs, changes in legislation, and a myriad of other factors, the system as a whole is naturally prone to errors which can sometimes be fatal.

There are many stakeholders responsible for providing safe patient care including not only healthcare workers and patients but administrators, researchers and policy makers. Nurses play an irreplaceable role in this system, being the eyes and ears of both the patients and the healthcare workers. The Registered Nurse has one of the most important roles in a culture of safety, due to the multifaceted nature of the profession.


According to the American Association of Colleges of Nursing, 28% of adverse reactions to medications and 42% of life-threatening events in healthcare are preventable. This error margin can also be attributed to many factors, one of which is the ratio of patients to RNs. For many Registered Nurses, patient ratios are simply too high to ensure for quality health care delivery.

Safe staffing may be one of the most common causes of errors, and job dissatisfaction among RNs. For example, 60% of nurses in one dialysis unit felt that there were simply not enough RNs on staff and 55% of them felt that there wasn't enough staff in general to provide effective medical care (Nephrology Nursing Journal, 30(2), p. 169-178, 2003). As a result, many RNs use their expertise in patient care, along with their collective voices, to lobby employers, legislators and policy makers to create staffing ratios that are based on acuity, experience and competence—not solely on a healthcare institution's bottom line.

There is a great deal of research to support this effort. Findings in one study showed that high patient ratios that resulted in the increased number of tasks RNs had to perform were correlated positively with an increased likelihood of the procedures not being done, being done late or being rushed. (Nephrology Nursing Journal, 35(2), 123-130.)

Another similar study found that actual RN staffing is directly associated with mortality rates. In 168 hospitals with patient to RN ratios ranging from 4:1 to 8:1, each patient included on the nurse's caseload experienced a 7% higher likelihood of dying within 30 days of hospital admission (Aiken, L.H., Clarke, S.P., Sloane, D.M., et al., 2002).

In light of these statistics, it is imperative that RNs understand clearly what their role is within the promotion, design and execution of safe patient care process. Patient safety can be defined as the freedom from any accidental injury that may occur facilitated by the establishment of operational systems that minimize the likelihood of errors as well as maximizing the likelihood of interception of any errors before they occur.

Thus the RN plays a significant role in both preventing errors and designing the systems that increase the likelihood that potential errors will be caught before they occur. As first hand health care providers as well as managers and leaders, the RN is one of the most essential members of a culture of safety.

As any RN can tell you, there are specific goals that must be considered when establishing safe healthcare processes. Whether it be avoiding needle sticks, preventing falls, determining safe staffing ratios or establishing safe medication reconciliation procedures, the RN has knowledge that others in the healthcare system do not. The hands-on experience of the RN, combined with systems based thinking, make Registered Nurses some of the most important decision makers in safety planning and error prevention.

The main components of high quality healthcare include: Safety (avoiding injury to patients from the care that is being given); effectiveness (services provided based on research-based practices to those who would benefit); patient-centered care (care that is completely respectful and responsive to the patient needs, values and preferences); timely care (efficient healthcare provided with the least amount of wait time or delays); efficiency (healthcare provided with little or no waste of equipment, time, supplies, energy); and equity (care that is provided without variance in quality due to elements such as gender, geographic location or socioeconomic status).

Each of these is the responsibility of the RN, and as such, RNs should be involved every step of the way when it comes to designing and implementing a Culture of Safety in Healthcare.

In a culture of safety, Registered nurses are the pivotal players in the delivery of safe and efficient healthcare.

RNs can help to increase patient safety as well by becoming competent leaders in the profession. Effective patient care is generally the delivery of patient care by members of a team; RN's directing non-registered nurses. RN's must know the standards, legal parameters and specific tasks that can be performed by members of the team so the system can work efficiently together. The nurse must also be a critical thinker and must be able to use all of this acquired knowledge in the delivery of safe patient care.

RNs can also help to increase patient safety by fulfilling their professional responsibility to become and remain lifelong learners.

Nursing education is a process, not a destination.

With all of the constant changes and revelations in the medical field, nurses must continue learning and staying on top of the latest and most significant changes and developments in order to insure that patients are receiving the highest quality of care. Advancement in the field can also include furthering the education level of RNs, with Baccalaureate and Master's prepared nurses being sound goals in progression.

Some RNs may even progress on to become APRNs, or advanced practice registered nurses. APRN's function independently as nurse practitioners, clinical nurse specialists, nurse anesthetists, and even nurse midwives.

Many professional nurses seek specialization in specific fields, as well, such as pediatrics. Certifications of this type usually require completion of additional education from an accredited program, recommendations from colleagues and the successful completion of a certification examination specific to the field.

The role of the RN in patient safety is a clear one; the education and experience of the RN plays a critical role when addressing patient healthcare needs and RNs should have an appropriate amount of time with each patient to efficiently perform the tasks that are required of them.

As we continue our journey through Nurses Week 2016 and aim to help you create a Culture of Safety within your own workplace, use our own RN's suggestions below to help guide you:

  • Take some time to look into the safe staffing laws in your state, if you aren't familiar with them, to see how your area deals with this important issue.
  • Join the safety committee on your unit or in your healthcare facility.
  • Familiarize yourself with reporting and review processes for critical incidents at your facility.
  • Learn about policy and procedure revision processes.
  • Attend a root cause analysis (RCA) or other review board process at your facility.
  • Contact your State Board of Nursing for more information on lobbying and legislation efforts as they relate to nursing and safety.
  • Collaborate with others in your unit to design and improve annual competency evaluations.
  • Read research studies, or create a research review peer group, to discuss EBP and safety.
  • Stay up to date on advancements by subscribing to newsletters, journals and nursing periodicals.
  • Focus on your patients, every shift, with every procedure, to ensure that you are providing high quality care that is patient centered.
  • Educate yourself, through conferences, certifications or by expanding your degree.
  • Be a role model for other nurses. Be honest. Be accountable. Be a leader.
  • Be a champion for a Culture of Safety, and let others know how to do the same.

Happy Nurses Week from all of us at