It is painful and distressing to read about this family's experience of care in a large, tertiary medical center with an international reputation for excellence. I am reminded of Nightingale's admonition in 1859 from the preface of Notes on Hospitals: "It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm."

The unfortunate message to the reader from this family narrative is that nothing went wrong, and yet the entire experience of care was suboptimal, with true potential for adverse events. This paradox-good surgical outcome but poor patient experience and possibility of harm-is probably more common than we would like to acknowledge. The gaps in care that this family describes have been identified by others, including 3 influential reports from the Institute of Medicine: To Err Is Human: Building a Safer Health System (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (2001), and Keeping Patients Safe: Transforming the Work Environment of Nurses (2004). Many of us have friends and loved ones whose hospital stories are similar. These publications and personal narratives call us as clinicians and health care leaders to do something.

I propose 5 actions to deal with the issues raised by the authors. These actions are designed for system-level intervention in a hospital setting.

1. Tell the story of this patient's experience of care-to the immediate caregivers as well as a broader hospital audience. Better yet, invite the patient and his spouse to participate in a Quality Grand Rounds. There are 2 objectives of this action: to potentially restore this patient's trust in the hospital, and second, to put the care team in the "shoes" of the patient.

2. Create a system to report and identify near misses. A number of hospitals have implemented blame-free reporting mechanisms for hospital staff. Front-line caregivers-and patients-see the problems. They need "hot line" means to report concerns.

3. Actively seek patient and family feedback during-not after-the hospital stay. After the patient leaves the hospital, it is probably too late to recover the patient's negative impression if something has gone wrong. Mechanisms like nurse manager rounding to solicit feedback or in-hospital TV-enabled surveys are 2 possible mechanisms.

4. Develop and train leaders who are accountable for a culture of safety, practice excellence, and service quality. In the acute hospital setting, the nurse manager is the unit-based "CEO," who should be accountable to attain clearly defined performance outcomes in areas of patient safety, workforce satisfaction, and service quality. Specific expectations need to be developed, outcomes measured, and incentives provided.

5. Design daily interdisciplinary rounds that incorporate the participation of all team members, including the patient and family. As obvious as this action appears, it is difficult to consistently ensure. Evaluate current practice, and create a "script" for rounds focused on the plan of care for each patient-including comfort in all dimensions as well as the patient's need for information.

This family's narrative raises issues about an inpatient experience of care that is likely to be more typical than we would like to admit as health care leaders. But change is possible if we acknowledge the problems we uncover and implement solutions with focus and determination-for the patients and families we serve.