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Comment & Response
August 12/26, 2013

Perceptions of Safety Are Shaped by the Hospital Environment—Reply

Author Affiliations
  • 1Department of Medicine, Johns Hopkins University, Baltimore, Maryland
  • 3Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland
  • 2Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland

Copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2013;173(15):1472-1473. doi:

In Reply We thank Smith and colleagues for their interest in our work and insightful comments. Our recently published Research Letter showed that 40% of hospitalists reported that their typical inpatient census exceeded safe levels at least monthly.1 When asked the direct question regarding perceived safest total number of inpatients that the individual health care provider could be responsible for at their practice during a typical shift, the median response was 15 (interquartile range, 10-20) patients. We wholeheartedly agree that for each institution, health care provider and patient mix and team structure can support a range of patient encounters. We further recognize that physician, team, hospital, and patient factors affect the number of encounters and report this in detail in a separate publication.2 For example, a younger inexperienced health care provider mix (physician factor), separate admitting teams (team factor), urban setting (hospital factor), or high-complexity patient case-mix (patient factor) may alter this workload threshold. A comprehensive framework is essential to understand workload, compare metrics across institutions, and provide a model for targeted interventions.

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