Improving the Culture of Patient Safety Through the Magnet

Improving the Culture of Patient Safety Through the Magnet® Journey

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Jane W. Swanson, PhD, RN, NEA-BC
Candice A. Tidwell, EdD, RN-BC

Abstract
This article outlines how one academic medical center‟s nursing service has developed programs to improve patient
safety and quality outcomes through the use of the Magnet Re-Designation Accreditation Process® and a shared
governance model. Successful programs have been implemented across the continuum of care. These programs
include educational initiatives that increased both the number of nurses with BSN degrees and specialty
certifications and also the number of patient-focused initiatives, such as a reduction in central line infection rates,
an increase in hand-washing compliance, and a decrease in fall rates. In this article we will describe how our
Magnet Re-Designation Accreditation Process® and shared governance model have contributed to strengthening our
culture of patient safety. The manner in which the Magnet components of transformational leadership; structural
empowerment; exemplary professional practice; new knowledge, innovation and improvement; andempirical
quality results have all contributed to improved patient safety are discussed.
Citation: Swanson, J., Tidwell, C., (September 30, 2011) "Improving the Culture of Patient Safety Through the
Magnet® Journey" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 1.
DOI: 10.3912/OJIN.Vol16No03Man01
Key words: Magnet Re-Designation Process®, shared governance, culture of safety, transformational leadership,
structural empowerment, innovation, empirical quality results, patient safety, unit-based councils, transforming
care at the bedside, TCAB, SBAR, communication, Central Line Associated Bloodstream Infection, CLABSI, falls
prevention, electronic medical record development, Magnet®
Cedars Sinai Medical Center (CSMC) (Cedars-Sinai) is a 958 bed, non-profit, medical center located in Los Angeles,
California, at the borders of Los Angeles, Beverly Hills, and Hollywood. The medical center was designated an
American Nurses Credentialing Center (ANCC) Magnet® hospital in 2000. Magnet re-designation was achieved in
2004 and 2008. In 2008, as a result of changes in Magnet re-designation criteria, Cedars-Sinai changed its focus
from Magnet‟s original 14 forces to the five Magnet components of transformational leadership; structural
empowerment; exemplary professional practice; new knowledge, innovations, and improvements; and improved
empirical outcomes (ANCC, 2008). Inherent to these processes is the focus on improved patient outcomes as
evidenced by not only meeting, but exceeding national quality benchmarks. As Magnet organizations mature and
Magnet-required structures and processes become part of staff members‟ usual behaviors, increasingly more
emphasis is placed on outcomes during the re-designation process. The purpose of this article is to describe the
alignment of Cedars-Sinai‟s structure and processes with the five Magnet components and link this alignment to
the development of a culture of safety resulting in improved patient care outcomes.
Although healthcare providers have traditionally avoided flaws or ineffective care processes, there has been a
reluctant acknowledgment that a percentage of patient complications may be related to errors in care. The
landmark study from the Institute of Medicine (Kohn, Corrigan, & Donaldson, 2000) shed new light on the extent
and complexity of systems errors that contributed to almost 100,000 patient deaths each year. From that time
forward, hospital leaders have focused on uncovering system-based failures and associated human factors in an
effort to prevent patient harm and optimize clinical outcomes. Cedars Sinai‟s leadership team shares this goal with
other acute care organizations. The commitment to building and sustaining a culture of safety requires a multifaceted approach. One aspect of this „culture‟ is that senior leadership is a critical component of establishing a
climate in which safety systems are most effective (Sammer, Lykens, Sing, Mains, & Lackan, 2010).

Magnet Component I: Transformational Leadership

Effective senior leadership...will continue to be, critical in a facility‟s growth in achieving Magnet standards.

Effective

senior leadership has been, and will continue to be, critical in a facility‟s growth in achieving Magnet standards.
Linda Burnes Bolton, Vice President for Nursing and Chief Nursing Officer at Cedar-Sinai, is nationally recognized as
a transformational leader. She has led the 2,800 nurses throughout the medical center, including inpatient, perioperative, and ambulatory settings, since 1996. She has been instrumental in the creation of the strategic plan for
nursing care; the development of the Geri and Richard Brawerman Nursing Institute for Staff Education and
Development; and the expansion of the nurse practitioner role in the organization. Cedars-Sinai was an early
adopter of the belief that teamwork and the engagement of nurses and the entire healthcare team is essential to
patient safety (Institute of Medicine, 2004). To foster an environment of engaged staff and improved patient safety
at CSMC, the shared governance (SG) structure was revised in 2006.
Key to the success of maintaining Magnet certification is an integration of the five Magnet components into the
facility‟s mission and vision statements. The Mission of Cedars-Sinai Nursing includes the words “committed to
engaging staff, patients and diverse community members to develop and provide excellent evidence based clinical
care for patients and the community served with respect for the beliefs and values of those who receive care”
(Cedars-Sinai intranet weblink, para. 1). The nursing mission is integrated into our 2011-2015 nursing strategic
plan that iterates the following six nursing strategic goals and objectives (See also Table):

 Sustain a culture of safety and quality in the delivery of patient- and family-centered care based on
evidence from research and practice

 Deliver exceptional, culturally relevant services to patients, families, and communities with respect for
their beliefs and values

 Provide exceptional, value-added care through the use of technology and adoption of safe, point-of-care,
efficient work practices

 Engage and develop a knowledge-based, diverse, multigenerational, optimally healthy nursing workforce
 Conduct, disseminate, and translate research to improve care and services for patients and community
 Attract and sustain financial support for nursing development, research, and service

Table. Cedars-Sinai Nursing Strategic Plan: Goals and Objectives for 2011-2015
Goal
Objective
Provide safe, high quality
 Adopt and maintain evidence-based standards in
clinical care based on
delivery of care
evidence
 Adopt and utilize core processes linked to
achieving quality targets
 Integrate
nurse-sensitive
indicators
in
Transforming-Care-at-the-Bedside targets (fall
prevention, pressure ulcers, restraint use)
 Enhance collaboration between nursing and
medical staff to improve work environment and
patient care processes
Deliver exceptional, culturally
 Expand School of Nursing and service programs
relevant services to patients,
for internships and nursing residency
families, and communities
 Achieve professional advancement targets by
supporting both on-site and web-based education
programs and certification programs




Deliver value-based care
through the adoption of
technology and improvement
in work practices





Engage and promote the
development of a diverse,
multigenerational, optimally
healthy workforce





Conduct clinical, translational
and health services research




Enhance philanthropy




Provide development resources and shared
governance participation at the unit level
Improve patient satisfaction through emotional
support, education, and physical comfort
Provide technology to monitor compliance with
regulatory and patient safety
Use benchmarking and best practice monitoring to
set targets for improvement
Produce standardized, evidence-based-practice
(EBP) plans of care within electronic medical
records that are customized to each patient
Ascribe to a philosophy of patient-family-centered
care
Foster environment that supports organizational
values
Facilitate strong collaboration with baccalaureate
and graduate nursing programs to support
academic progression
Provide additional resources to mentor nurses’
participation in EBP
Enhance nurses understanding of EBP and
application to patient care and quality outcomes
Endow the Nursing Institute to develop Scholars
and Fellows nursing research and practice skills
Obtain financial support for endowed chairs in
leadership, research, practice, education, and
community service

Magnet Component II: Structural Empowerment

...issues and unit-based initiatives percolate from the grassroots base of staff nurses upward toward the leadership of the

patient care services.

The principles of shared governance (SG) that guided this structural revision included

information sharing, idea generation for improving patient care, consensus building between team members,
fostering individual accountability, and increasing team responsibility(Porter-O‟Grady, 2002). The current SG
structure has been in place since 2007. This structure includes the Divisional Practice Councils, Transforming Care
at the Bedside initiatives, and Orem‟s theory describing self-care deficits.

One element of the SG structure (See Figure) includes the unit-based/divisional practice councils that meet
monthly to address issues related to unique patient populations, operations, and quality outcomes. The unit-based
councils are organized into divisional councils for communication and follow through, as issues and unit-based
initiatives percolate from the grassroots base of staff nurses upward toward the leadership of the patient care
services. Members of unit-based councils monitor staff practice, competency, peer-to-peer evaluation, and clinical
advancement projects. Observations, ideas, and recommendations are forwarded to the Specialty-Specific
Divisional Councils (medical-surgical nursing, rehabilitation, and critical care) and the Outpatient Services Council
as well as the following additional councils:
Vital Services Council -- (emergency department, procedure centers, and preoperative services) -validates that safety standards are consistently implemented
Nursing Research Council -- builds research capacity, enhances evidence-based practice skills, develops
the annual research conference, and participates in the Institutional Review Board process
Educational Council -- facilitates staff and patient education, staff competencies, certification and
educational goals, and academic education
Quality Council (named CALNOC/PI) -- monitors clinical outcomes, nursing sensitive outcomes, and
regulatory requirements, facilitating the incorporation of these outcomes/requirements into practice
Nursing Executive Council -- provides oversight for operational issues, succession planning, leadership
development, strategic planning, patient satisfaction, system improvements, and quality improvement.
The Coordinating Council membership is comprised of the co-chairs of the divisional and specialty councils. It is
responsible for shared governance oversight, approval of council recommendations, the professional practice
model, and overall strategic planning.
Figure. Integration of Shared Governance with Magnet Components to Promote Patient Safety

Cedars-Sinai Medical Center...ensure[d] that these medical-surgical staff nurses, who often understand a patient‟s needs

best, were central to the creation, monitoring, and evaluation of performance improvement programs.

Another element of

the SG Model includes the Transforming Care at the Bedside (TCAB) initiatives, designed to provide a process for
recognizing and integrating the staff nurse‟s perspective and expertise into addressing and resolving clinically
focused issues (Rutherford, Moen, & Taylor, 2009). The Robert Wood Johnson Foundation and the Institute for
HealthCare Improvement have recognized the crucial role of medical-surgical staff nurses in enhancing patient
safety and quality outcomes. Cedars-Sinai Medical Center adopted this recognition as part of the SG model to
ensure that these medical-surgical staff nurses, who often understand a patient‟s needs best, were central to the
creation, monitoring, and evaluation of performance improvement programs. These professionals are encouraged
to participate in unit-based TCAB initiatives, which are usually labeled „tests of change.‟ These unit-based initiatives

originated with the TCAB project. Tests of change, using for example, the Plan-Do-Study-Act (PDSA) process
(Institute for Healthcare Improvement, 2008), are part of the Cedar-Sinai model for improvement. Since 2005,
nurses have been directly involved in TCAB initiatives, including the reduction of falls, prevention/healing of dermal
ulcers, implementation of Rapid Response Teams, and use of SBAR (situation, background, assessment and
recommendation) communication for all patient handoffs.

Use of the trending reports by the nurse directors and nurse managers helped the direct care nurses on the units to

visualize documented improvements and accomplishments, as well as areas where additional efforts were needed.

This

participation in TCAB, and the nurses‟ ability to speak to the organization‟s evolving quality improvements, were
very evident during the 2008 ANCC Magnet re-designation visit. During this visit, nursing staff and the entire
organization utilized dashboards with key clinical indicators and metrics to benchmark their patients‟ experiences
with patient experiences in comparable organizations. This benchmarking provided an organization-wide,
standardized approach comparing Cedar-Sinai‟s scores with those of the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) scores. These scores include, among other measures, quality scores
regarding core measures, nursing sensitive indicators for falls, hospital acquired pressure ulcer and ventilator
acquired pneumonia incidence, and readmission within thirty days. Through the collecting, analyzing, and reporting
of these multiple nursing quality indicators, nurses were involved in major activities that heightened their
awareness regarding improved patient care and nursing practice. Use of the trending reports by the nurse directors
and nurse managers helped the direct care nurses on the units to visualize documented improvements and
accomplishments, as well as areas where additional efforts were needed.
The final element in the SG model at Cedars-Sinai Medical Center is Orem‟s (2001) self-care deficit theory that
guides the professional practice of nursing throughout the facility. In its simplest form, this theory explains that
patients with illnesses or injuries lack the ability for self-care (a lack known as the „deficit‟) and seek out healthcare
providers. Through the delivery of „helping services,‟ the nurse assists the patient and/or family members to regain
as many self-care skills, known as „agency,‟ as is reasonable for the situation (George, 1995).
By 2007 the SG model was firmly in place within the facility. The revision of the Magnet model in 2008 prompted a
validation processes to ensure that the organization maintained its patient-centered focus and enhanced its culture
of safety. Sustaining systems that recognize both the reality and consequences of human error requires an
investment of human and financial capital to ensure a meaningful and effective, house-wide approach. The use of
smart intravenous pumps, for example, helps ensure the appropriate care is delivered to patients and should be
routinely utilized by nursing staff (Harding, Connolly, & Wilkerson, 2011).

Magnet Component III: Exemplary Professional Practice

One

characteristic

of exemplary

professional practice

is meticulous

attention

to

communication

processes.

One

characteristic of exemplary professional practice is meticulous attention to communication processes. Educators
and Clinical Nurse Specialists provided staff education at the unit level as we initiated the use of SBAR (described
above) in 2006. Educational tools were developed to teach staff how to use SBAR communication, and staff had the
opportunity to role play using the SBAR format. This use of SBAR has created a standardized approach to
information sharing. It has created a shared mental model for effective information transfer by providing a
standardized structure for concise, factual communication among clinicians, whether it is nurse-to-nurse, doctorto–doctor, or nurse-to-doctor communication. It is now used to ensure that patient information is consistently and
accurately communicated, especially during critical events, shift handoffs, and patient transfers between levels of
care.

In order to sustain a culture of safety and quality in the delivery of patient care we have also developed the Medical
Doctor-Registered Nurse collaborative that strives to create a work environment that is collaborative and
supportive for improving communication and subsequent patient outcomes. Additionally, the Neonatal Intensive
Care Unit (NICU) team has implemented safety advocacy strategies that enhance constructive and assertive
communication skills to use when identifying potentially hazardous clinical situations.
In another initiative critical care nurses on one of our intensive care units addressed the device-related pressure
ulcers that were resulting from the nasal-gastric-tube placement. The nurses completed a „test–of-change‟ by
developing a new method of taping the nasal-gastric tube. This new method, called the ‟I tape‟ method, eliminated
nasal-dermal ulcers. Soon this process was spread via the shared governance council system to all the intensive
care units.

As of this writing, the NICU has experienced 380 days without any occurrence of a line infection.

In 2005 central line

infections were higher than national benchmarks. In order to improve patient safety and quality of care, a new set
of safety practices was initiated in the form of a Central Line Bundle (Galpern, Guerreno, Tu, & Wise, 2008). This
nationally recognized, evidence-based practice consists of five steps that reduce central line infections. These steps
include the hand-hygiene practice of cleaning hands prior to patient care and following patient care, selecting the
best possible insertion site for the central line, using proper skin preparation before inserting the line, using
maximal barrier precautions throughout, and removing the catheter as soon as possible. Since 2010 the number of
central line infections has been zero during most of the months. Additionally, the NICU team joined the California
Children‟s Services Quality Initiative in 2008 and has reduced the Central-Line-Associated Bloodstream Infection
(CLABSI) rate down to 0.3 per 100,000 central line days. As of this writing, the NICU has experienced 380 days
without any occurrence of a line infection.
In 2009 the observations of hand washing indicated that only 60% of nurses and other care providers were
consistently washing their hands both before and after patient contact. A major initiative was launched to insure
that hand washing was accomplished both before and after patient care, including a zero tolerance for infections
and failure to wash the hands. Since 2010 more than 1,900 observations a month have revealed that 94% of all
care providers and 99% of nurses are consistently washing their hands before and after patient contact.
A culture of safety has also been enhanced by the involvement of staff nurses in the process by which our
professional nursing practice standards are developed, implemented, and monitored for their impact on patient
care. One example of this staff nurse involvement was seen as we were developing strategies to prevent patient
falls. Although it has been suggested that all four side rails of the bed be raised in the interest of patient safety and
to prevent falls (Nettina, 2010), the experiences at Cedars-Sinai have not supported this practice. This practice not
only failed to reduce falls, it actually appeared to prompt patients to climb over the side rails, resulting in increased
fall and injury rates. Additionally, the Centers for Medicare and Medicaid Services has stated that having all four
side rails raised on a bed is considered a restraint when used to limit a patient‟s ability to move freely (U.S.
Department of Health and Human Services, 2006). Our nurses do not follow this practice. Our falls prevention and
intervention policies and procedures are routinely reviewed and updated based on current literature, evidence, and
compliance with regulations. This dedication to patient safety has resulted in a 19% decrease in patient falls over
the last year as well as consistently maintaining a lower incidence of patient falls throughout our facility as
compared to the national Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarks for the most recent
two years.
Improving the safety of patient care is not limited to the inpatient areas of Cedars Sinai Medical Center (CSMC).
Nurses have the opportunity to volunteer in more than 200 Cedars-Sinai-sponsored health fairs annually at senior
citizen centers, churches, and synagogues where vaccines are available and screening for hypertension, high
glucose, and cholesterol is provided. Nutrition counseling, as well as follow-up care services, are offered. CedarsSinai also has two mobile vans staffed with pediatric nurse practitioners that go daily to elementary schools to
provide pediatric screenings and immunizations, as well as vision and hearing testing.

Inherent to the successful practice of nursing care is the work environment created by senior leadership. Stellar
patient care delivered by well-educated staff nurses is enhanced when an organization integrates safety-related
health promotion initiatives for its employees into the strategic plan. Recently implemented infection control
policies, such as optimizing hand-hygiene procedures and visitor limitations during the flu season, have resulted in
fewer staff member sick calls. CSMC also offers employees no-cost vaccinations and counseling services through
the Employee Assistance Program (EAP). Leadership‟s attention to maintaining a safe and healthy workplace
environment for all patient care providers is threaded throughout the facility‟s mission and vision statements.
Cedars-Sinai‟s exemplary professional practice and achievement of safe patient outcomes have been facilitated by
the outstanding work and commitment to nursing practice on the part Cedars-Sinai nurses. Each year more than
100 nurses are recognized with nursing excellence awards to reflect their extraordinary ability and demonstrate
how much they are valued by our patients and fellow staff members. Friends of nursing awards are also presented
to non-nurses who have helped nurses make a difference, in appreciation of their support. The high level of
collaboration and support among nurses, physicians, ancillary staff, and administrators has been another pivotal
link in the facility‟s commitment to foster a culture devoted to patient safety.

Magnet Component IV: New Knowledge, Innovation, and Improvements
Since 2006, the critical care nurses have used their shared governance unit and divisional practice councils as a
mechanism to incorporate new ideas, innovative interventions, and evidence-based practices related to patient
care. The group worked to ensure: (a) standardization of equipment, (b) consistent comprehensive assessment of
critically ill patients, (c) utilization of resources and evidence-based practices, and (d) compliance to critical care
nursing policies and procedures. Every month, for two hours, the Divisional Practice Council meets to design critical
care nursing guidelines focusing on concepts applicable to clinical practice in the intensive care units. These
practice guidelines have included both clinical and managerial considerations.
In 2008 Cedars-Sinai began development of an electronic medical record that was consistent across the medical
center. Nurses were involved every step of the way and played an essential role in defining and implementing the
strategies for this electronic system. Over 500 nurses participated in decisions related to vendor selection and
clinical designs to determine the safest way to integrate the system. Nurses continue to work on each of the
committees and task forces as this system evolves. The focus of these committees ranges from registration and
admission, to electronic documentation, and to implementation of the next phases, that include physician order
management and ambulatory systems integration.

Magnet Component V: Empirical Quality Results
A number of operational and safety outcomes have been presented above. This section will focus on two additional
improvements that have increased the quality and safety of care provided at Cedars-Sinai. One improvement
relates to strengthening the educational preparation of nurses; the other relates to strengthening care in the
operating room.
The educational preparation of our nurses was markedly strengthened when, in 2002, Geri and Richard Brawerman
endowed the Geri and Richard Brawerman Nursing Institute that has helped more than 2,800 nurses participate in
educational and professional-development offerings. Funds from this Endowment have been used to renovate an
education classroom and to purchase simulation equipment and education modules. These funds have also
supported educational scholarships for leadership and development programs, research, and leadership fellowships,
and also nursing staff presentations at regional and national conferences. Furthermore, these endowment funds
have also been used to increase nurses‟ engagement with on-site education programs, specialty review courses,
and mentoring programs. In 2004, 11% of the direct care nurses held specialty certification, 42% had obtained
their BSN degree, and less than 1% had a MSN degree. By 2011 53% of direct care nurses had attained specialty
certification and 73% had obtained their BSN degree. Additionally 9% of the direct care nursing staff had obtained
a Master‟s degree. During the same timeframe the nursing leadership, including managers and directors, increased
from 70% having a Master‟s degree to 97% having this degree. As noted in the 2010 Future of Nursing report
(IOM, 2010), increased education and specialty certification are relevant to improving the delivery of culturally
relevant, safe, quality services to patients, families, and communities.

The

McOR

project was a test of change modeled after a McDonald‟s Corporation methodology designed to

streamline work processes.

A quality improvement project targeted at improving patient flow in the operating

room has also improved the safety of the care provided at Cedars Sinai. The McOR project was a test of change
modeled after a McDonald‟s Corporation methodology designed to streamline work processes. This change sought
to identify processes that would meet the increased demand for operating room time by using both scheduled time
and blocks of time more effectively. This project evaluated the overall patient flow, streamlined processes, and
reduced waste, allowing for the scheduling of more surgeries per day. Prior to the start of this project only 6% of
the patients were in the operating room and ready for the 7:30 AM start time. However after the process changes
were trialed and implemented, 95% of the cases were ready by 7:30 AM. Additionally physician satisfaction
improved and distractions in the operating room were minimized, thus decreasing the occurrence of adverse
events.

Conclusion
This article has described how Cedars-Sinai Medical Center has achieved and maintained Magnet status through the
development of effective communication, structures, and processes that have been built over the years and
maintained by transformational leadership. Shared governance, including practice councils, transforming care at
the bedside initiatives, and a theoretical basis to guide care, have empowered nurses at all levels to grow
professionally and develop structures and processes that have aligned to produce exemplary practices and
outcomes, including the development of a culture of safety at CSMC.

Authors
Jane
W.
E-mail: [email protected]

Swanson,

PhD,

RN,

NEA-BC

Dr. Swanson is the Director of the Geri and Richard Brawerman Nursing Institute for Education and Professional
Development at Cedars-Sinai Medical Center (Los Angeles, CA) and also the Magnet Program Director. Her nursing
career includes forty years of nursing experience in nursing education, administration, and leadership. She received
her BSN from the Medical College of Georgia (Augusta), her MSN from Arizona State University in Tempe, AZ, and
her PhD in Nursing from the University of Texas, Medical Brach, Galveston, Texas. Dr. Swanson is a Navy Nurse
Corps retired Captain.
Candice
A.
E-mail: [email protected]

Tidwell,

EdD,

RN-BC

Dr. Tidwell has been the Education Program Coordinator at Cedars-Sinai Medical Center since 2009. She received
her BSN from Loma Linda University, her MN from the University of California in Los Angeles School of Nursing, and
her EdD degree in Educational Leadership from the University of Phoenix.

References
ANCC. (2008). Recognizing nursing excellence: Application manual: Magnet recognition program. Silver Springs,
MD: American Nurses Credentialing Center.
Committee on the Work Environment for Nurses and Patient Safety. (2004). Keeping patients safe: Transforming
the work environment of nurses. Washington, DC: Institute of Medicine of the National Academies.

Galpern, D., Guerreno, A., Tu, A., & Wise, L. (2008). Effectiveness of central line bundle campaign on line
associated infections in intensive care units. Surgery, 144(4), 492-495.
George, J.B. (1995). Nursing theories: The base for professional nursing practice. Norwalk, CT: Appleton and
Lange.
Harding, A.D., Connolly, M.W., & Wilkerson, T.O. (2011). Nurses' risk without using smart pumps. JONA's
Healthcare Law, Ethics, & Regulation, 13(1), 17-20.
Institute for Healthcare Improvement.
from www.ihi.org/knowledge.

(2008). Model

for

improvement.

Retrieved

August

12,

2011

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health.Washington, DC: National
Academy Press.
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health
system. Washington, DC: National Academy Press.
Porter-O‟Grady, T., & Mallach, K. (2002). Quantum leadership: A textbook of new leadership. Gaitersburg, MD:
Aspen Publication.
Nettina, S. M. (Ed.) (2010). Lippincott manual of nursing practice. Philadelphia, PA: Lippincott Williams & Wilkins.
Orem, D.E. (2001). Nursing: Concpets of care (6th ed.). St. Louis, MO: Mosby, Inc.
Rutherford, R., Moen, R., & Taylor, J. (2009). TCAB: The „how‟ and the what‟. American Journal of Nursing,
109(11), supplement.
Sammer, C.E., Lykens, K., Singh, K.P., Mains, D.A., & Lackan, N.A. (2010). What is patient safety culture? A
review of the literature. Journal of Nursing Scholarship, 42(2), 56-165.
U.S. Department of Health and Human Services. (2006). Centers for Medicare & Medicaid services: Federal
register, Part IV, 42 CFR Part 482 (71) 236, 71378-71428.

© 2011 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2011