In the 1990s, hospital industry consultants and executives made dramatic changes to California's hospitals, completely restructuring care delivery. They reduced the number of licensed beds and replaced many licensed nurse staff with unlicensed personnel who were expected to perform complex nursing functions with little or no training. Managed care meant that only the most seriously ill patients were admitted to hospital. In 1999, the nonprofit Institute for Health and Socio-Economic Policy published a report of California's nurse staffing ratios.1 Primary data sources included 18.2 million patient discharge records of California hospitals, hospital financial and bed data, and aggregated data from American Hospital Association sources on registered nurse employment levels. The report's stark conclusion was that The portrait is one of fewer full-time registered nurses caring for the same or increased number of patients, who are largely more ill, in far fewer beds. These significantly more ill patients are thus in need of more complex and intensive care from fewer full-time registered nurses. Without addressing staffing ratios at the level of policy rather than the market, this vicious circle is one that can only grow. The California Nurses Association (CNA) noted that patients were being transferred quickly out of critical care units. Patients in transitional units and medical-surgical wards were often as sick as those receiving their nursing care in critical units, although the nurse-to-patient ratios were far lower. Such transfers out of intensive care units were simply unsafe. Nurses have become increasingly reluctant to work in such unsafe facilities. A 1997 survey by the California Board of Registered Nursing found that only 60% of registered nurses holding active licenses chose to work in hospitals.2 Why are registered nurses steering clear of hospitals? The number one reason, cited by nurses in survey after survey, is unsafe staffing ratios.3 With about 100,000 deaths a year in hospitals caused by medical error,4 the unsafe hospital atmosphere keeps nurses away. Hospital industry groups argue that they are already overregulated, that they need flexibility, and that they consult the staffing guidelines of professional societies to ensure safe care. But they are being disingenuous. The experience at the CNA is that the industry abuses flexibility, ignores voluntary guidelines, and continues to push staff nurses to care for yet more patients. Hospital industry groups regularly staff hospitals by coercing nurses to work mandatory overtime. They will not regulate themselves. Hospitals must implement suitable staffing ratios that ensure that skilled nurses—who are often the interceptors of medical errors—are present in proper numbers for safe patient care. In October 1999, California introduced landmark legislation that made it the first US state to mandate safe licensed nurse-to-patient ratios in all acute care units. This extended the 25-year California tradition of regulating nurse-to-patient ratios in intensive care units and surgical departments. The regulation for intensive care units stated that 1 licensed nurse should be on staff for every 2 patients, with the stipulation that more nurses should be employed according to the intensity of patient need. The new law, AB 394,5 will extend this system of staffing beyond critical care to all units. The California Department of Health Services will establish what the minimum nurse-to-patient ratios will be in these units. As is the case with intensive care settings, the bill requires that additional nurses be added in accordance with a patient classification system based on the severity of patient need. If a hospital does not supply more nurses when they are needed for patient care, it will be deemed noncompliant and may be cited. With the enactment of AB 394 and the establishment of statewide safe-staffing ratios, the CNA hopes that nurses will return to hospital floors, restoring uniform safety standards for everyone.