It’s the evening surge at a busy ED where all beds are occupied. Several admitted patients – including 2 critically ill – are waiting for rooms upstairs. A quick glance reveals a full waiting room with multiple potentially sick patients. Then, 2 new patients arrive via EMS. Each will require immediate stabilizing interventions. If nursing resources were not already overwhelmed, they now will be. In the blink of an eye, this setup has created one of the most high-risk practice environments in emergency medicine. Yet, few emergency physicians would recognize it as such or even think twice about it. After all, it’s just another day.

But consider this: Decreasing the nurse-to-patient ratio immediately increases the frequency of medication errors and all-cause mortality for all patients in the ED — not only the critically ill ones who just arrived. In fact, there is strong evidence to suggest that protected emergency nursing ratios are key not only for patient safety, but also for departmental efficiency. So, why is it controversial to ask that EDs provide adequate nursing staffing?

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