When a system failure or human error leads to preventable patient harm, it offers care providers the challenge and the opportunity of disclosure: a challenge to step up and take the risk of treating patients and families in the way that we would wish to be treated and an opportunity to provide a healing experience both for patient families and caregivers involved in the event. When it is clear that our care has caused preventable harm and we allow a conspiracy of silence to betray those who have put their faith in us, we inflict the impact and pain that is nothing short of a "hit and run" accident. Four patient stories illustrate how the lives of family members would have been different if a new disclosure practice had been in place when they experienced the preventable loss of their loved ones. We view disclosure through their eyes. Their message is to hospital leaders. Historically, only the most courageous hospital leaders had the intestinal fortitude to insist that their organizations practice full disclosure. Now that the National Quality Forum disclosure safe practice has become a national standard, all will have to step up to be in compliance or explain to their communities why they will not.
From the *Parents of Infants and Children with Kernicterus; †Consumers Advancing Patient Safety, Chicago, Illinois; ‡Community Emergency Healthcare Initiative, Austin, Texas; §Josie King Foundation, Baltimore, Maryland; ∥Colorado Division (Pueblo, Colorado), and ¶American Division (New York, New York), Persons United Limiting Substandards and Errors in Healthcare; and #Texas Medical Institute of Technology, Austin, Texas.
Correspondence: Charles R. Denham, MD, Texas Medical Institute of Technology, 3011 North Inter-regional Highway-35, Austin, TX 78722 (e-mail: Charles_Denham@tmit1.org).