H ospitals and health care systems facing capacity strain due to changes in patient volume, patient acuity, or resource allocation may see increases in safety events as teams adapt to new stressors. Organizations need to establish and sustain cultures that support timely and honest reporting of safety events. Nurses are pivotal in promoting patient safety, as they make up the largest health care discipline. Research demonstrates that improved nursing resources in terms of work environment, staffing, and education can be associated with improvement in quality and patient safety outcomes. 1 PROBLEM Starting in 2008, nursing leadership at a large quaternary care, pediatric medical center recognized that expansion in patient census and acuity was posing challenges for safety management