In August, Dr. Donald M. Berwick presented the report from the independent National Advisory Group on the Safety of Patients in England (A Promise to Learn — A Commitment to Act: Improving the Safety of Patients in England) to Prime Minister David Cameron in London. The “Berwick Report” reflects on serious problems at the Mid Staffordshire NHS Foundation Trust that arose over several years, and the abysmal care received by patients at the trust’s Stafford Hospital in Stafford, England, during that time. I served on the advisory group, and I’m still asking how a trusted organization could deteriorate so completely without the leaders’ awareness or action? Could it happen elsewhere? How can we, as leaders, prevent these failures in the future?