The number of older persons in the United States is rapidly growing and, based on this growth projection, the number of consumers needing nursing home (NH) care will likely triple in the next 10 years. Although NHs have been bombarded and scrutinized about the care that they provide, the concept of safety (specifically, error prevention) remains at the margin of most quality improvement efforts. The purpose of this review is to explore what has recently been written (2000-2005) about the evolution of the NH as an organization focused on safety and the most critical clinical processes that must be closely monitored for a safe NH environment to occur. After a thorough review of both organizational and clinical NH literature, 30 organizational studies and 39 clinically based studies were reviewed. The review revealed that, organizationally, teamwork, communication, and leadership all were critical in resident and staff outcomes and clinically, assessment was an important missing process at critical points in the residents' care for prevention and timely treatment of potentially dangerous conditions. The value of the registered nurse (RN) in this setting was clear in the many assessment issues noted and the lack of RN guidance for adherence to recognized practice guidelines. To explicate the role of the RN, first, better outcome measures must be developed that are nurse sensitive. A second clear agenda for NH research is the explication of the role of leadership, particularly nursing leadership, to create an environment where open and accurate communication can be accomplished among all of the diverse NH roles. This will help all members of the team to identify care improvement opportunities. Finally, a new frontier for the NH setting is the use of technology and the need to harness the information that has set in the NH system for years. Information mastery for staff and leadership is a necessary aspect of the organization that must be developed to provide sound information for strategic and focused change to occur.