• HCOs and labor organizations representing nursing staff should establish policies and practices designed to prevent nurses who provide direct patient care from working longer than 12 hours in a 24-hour period and in excess of 60 hours per 7-day period.

• Schools of nursing, state boards of nursing, and HCOs should educate nurses about the threats to patient safety caused by fatigue.

Enabling nursing staff to collaborate with other health care personnel in identifying high-risk and inefficient work processes and workspaces and (re)designing them for patient safety and efficiency is also essential. Moreover, documentation practices are in great need of redesign. However, this cannot be accomplished solely by nursing staff and internal HCO efforts. Because many documentation practices are driven by external parties, such as regulators and oversight organizations, these entities will need to assist in the redesign of documentation practices. To address these needs, the committee makes the following recommendations:

• Surveillance of patient health status.

• Patient transfers and other patient hand-offs.

• Complex patient care processes.

• Non–value-added activities performed by nurses, such as locating and obtaining supplies, looking for personnel, completing redundant and unnecessary documentation, and compensating for poor communication systems.