Center for Evidence and Practice Improvement (Dr Ricciardi) and Center for Quality Improvement and Patient Safety (Ms Shofer), Agency for Healthcare Research and Quality, Rockville, Maryland.

Correspondence: Richard Ricciardi, PhD, NP, Agency for Healthcare Research and Quality, Rockville, MD 20850 ([email protected]).

This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.The authors declare no conflict of interest.