About 5 years ago, I wrote an article for the WAVE on this subject based on a patient of mine who experienced a serious medical error while under my care at a SNF. As I reflect on that case, I recall that I immediately sought advice from the referring colleague and from a trusted colleague. I then reported the error to the administration and was relieved that they supported full disclosure. I disclosed the serious medication error to the patient and his wife with sensitivity, but the experience was emotionally traumatic for them and those involved with their care. In retrospect, our response was reactive and done without the support of HR, clinical psychologist, risk management, or the counsel of our liability carriers.