time, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period. To this end:

  • 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:

Recommendation 6-2. HCOs should provide nursing leadership with resources that enable them to design the nursing work environment and care processes to reduce errors. These efforts must directly involve direct-care nurses throughout all phases of the work design and should concentrate on errors associated with:

  • 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.

Recommendation 6-3. HCOs should address handwashing and medication administration among their first work design initiatives.

Recommendation 6-4. Regulators; leaders in health care; and experts in nursing, law, informatics, and related disciplines should jointly convene to identify strategies for safely reducing the burden associated with patient and work-related documentation.

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