Delirium is considered a patient safety problem that can be prevented with specific care practices in the hospital. This commentary reviews an incident involving a patient with delirium and describes evidence-based practices to manage the condition, such as avoiding medications that precipitate confusion, maintaining an environment that fosters orientation (light during the day, dark at night), and use of low-dose antipsychotic medications on a short-term basis if nonpharmacological approaches fail. The authors emphasize the importance of timely diagnosis and treatment of delirium.