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They told RNs to keep the forms in their locker and helped them understand that the form would help protect their license in case anything ever happened. After the PPC collected ADOs, it would generate patient care reports based on the documentation and present them at meetings of the healthcare system���s board of directors during public comment periods. ���Nurses started ���lling them out and managers started paying attention because they knew we were making reports and taking them downtown to the county board,��� said Ahmad, a critical care nurse. ���The hospital supervisors were not giving the commissioners an accurate picture. Our reports said, ���No, this is not true. This is actually what���s happening.��� We were able to put a little fear in those supervisors.��� Once the ADO drive kicked into full gear, staf���ng improved greatly and nursing supervisors actually made efforts to correct unsafe staf���ng situations. ���Before, they would just hang up the phone on you,��� said Ahmad. And the ADO drive helped prevent layoffs that were proposed by the hospital at one point because nurses were able to show that more, not less, staf���ng was desperately needed. Today, staf���ng is still not ideal, but nurses are routinely using ADOs and understand that they have the power to improve unsafe conditions. ���It���s caught on. Nurses understand that this is their protection,��� said Ahmad. ���Instead of something that���s just verbal, if something happens, I have this piece of paper to prove I called you and told you I opposed this unsafe assignment. The ADOs have really been successful in making management understand that staf���ng is a shared responsibility. Our attitude to managers is, ���You���re going to write me up? I���m writing YOU up!������ ���Lucia Hwang Studies show ratios not only save lives, but save money Multiple research articles demonstrate how improved nurse-topatient ratios reduce complications, shorten hospital length of stay, improve patient outcomes, increase nurse satisfaction, and reduce the high costs of nurse turnover. Improved nurse-topatient ratios make economic sense for hospitals in response to the current crisis in healthcare spending. RN-to-patient ratios have been demonstrated to produce signi���cant long-term savings for hospitals by reducing patient costs. ��� (2012) ���State-mandated nurse staffing levels alleviate workloads, leading to lower patient mortality and higher nurse satisfaction.��� Agency for Healthcare Research and Quality (AHRQ) Fewer patient deaths: 30-day mortality rates were 10 to 13 percent lower in California than in other states. ��� (2011) ���Quality and cost analysis of nurse staffing, discharge, preparation, and postdischarge.��� Health Services Research Investment in nursing care hours better prepares patients for discharge. Cost analysis projected total savings from increase in RN staf���ng and decrease in RN overtime of $11.64 million and $544,000 annually. ��� (2011) ���Nurse staffing and inpatient hospital mortality.��� The New England Journal of Medicine Fewer RNs is associated with increased mortality and decreased reimbursements, which reinforces the need to match staffing with patients��� needs for nursing care. ��� (2010) ���Nurse staffing and patient outcomes in critical care: A concise review.��� Critical Care Medicine Decreased nurse staffing is associated with adverse outcomes in intensive care unit patients. ��� (2009) ���The economic value of professional nursing.��� Medical Care Adding 133,000 RNs to the acute-care hospital workforce across the United States would produce medical savings estimated at $6.1 billion in reduced patient care costs. ��� (2008) ���The cost of nurse-sensitive adverse events.��� Journal of Nursing Administration The odds of pneumonia occurring in surgical patients decreased with additional registered nurse hours per patient day. Each additional case of hospital-acquired pneumonia increased the cost per surgical case by an average of $1,029. ��� (2008) ���The impact of medical errors on ninety-day costs and outcomes: An examination of surgical patients.��� Health Services Research Preventing medical errors reduces loss of life and could N AT I O N A L N U R S E 19