Agency for Healthcare Research and Quality, Rockville, Maryland.

Correspondence: Carolyn M. Clancy, MD, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850 (carolyn.clancy@ahrq.hhs.gov).

The author declares no conflict of interest.

AHRQ Commentary: This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.