Document Type

Paper- Restricted to Campus Access

Publication Date


Faculty Mentor

Catherine van de Ruit


Front line clinicians and their administration play a vital role in undertaking the lives of many patients, however, organizational factors within the US healthcare system ultimately result in unsafe patient care. Unsafe care puts patients at risk of medical complications, and higher infection rates that contribute to preventable mortality and morbidity. This paper considers how and why organizational factors lead to unsafe patient outcomes by performing secondary analysis of qualitative data from 17 surgical departments nationwide, consisting of 255 individual in-depth interviews of frontline surgical clinicians and administrators from 2012-2015. Data collection was partnered between AHRQ, the Armstrong Institute for Patient Safety at Johns Hopkins University, and the University of Pennsylvania. Findings from this analysis highlight four categories that contribute to unsafe patient care: high patient to nurse ratios, communication failures among surgical staff, hostile environments within surgical departments and limited regulation of sanitation and patient safety protocols. The detrimental effects of unsafe patient care emphasizes the need for future research investigating how to change factors within the healthcare system that foster unsafe patient care.


Presented as part of the Ursinus College Celebration of Student Achievement (CoSA) held April 23 – April 30, 2020.

The downloadable file is a PowerPoint slide presentation with recorded audio commentary. Click the speaker button on each slide to hear the attached audio.


Available to Ursinus community only.