I know who it is as soon as he says hello. It is impossible to ignore the heaviness in his voice and I instinctively know that Dr. Greene is calling to share additional information regarding Joey Frank's death. Although it has been several weeks since the young boy died during cardiac surgery, I have been anticipating this call. From our earliest conversations, there had been the slender yet real possibility that the child's death might have been the result of a medical error. As I hear Dr. Greene say, "Joey's death was caused by an anesthesia error that could have been prevented," the questions that I know the family will have, and that Dr. Greene must have as well, begin to formulate in my mind. "What are my next steps," he asks. Understandably, Dr. Greene wonders whether he should involve the anesthesiologist, apologize directly, or bring in legal counsel. We both agree that the next step is for us to meet the next morning to prepare for the disclosure conversation with Mr. and Mrs. Franks. Before saying goodbye, I remind him that by building a good foundation with Joey's parents, we have worked together to establish trust following the devastating loss of their son. This does not mean that the disclosure conversation will not be extremely difficult for everyone, and there certainly will be many difficult conversations that follow. By continuing to share information and keep all lines of communication open and honest with the Franks, Dr. Greene and the hospital will show a commitment to the assurances given to the Franks the day Joey died that they would always be told the truth and that 'walls' would not go up.

In preparation for my meeting with Dr. Greene, I reflect back on what Mr. and Mrs. Franks said when they received the shocking news of Joey's death. They wanted to know why it happened and if there was anything that could have been done to prevent their son's death. In order to continue to meet the expectations of the Franks, I need to assist Dr. Greene in preparing to address these and other questions during the disclosure conversation. Any inability to address their concerns could be perceived by the Franks as 'hiding' something or evidence a lack of compassion, openness, and honesty in discussing the facts regarding Joey's death, halting further communication and breaking the fragile trust existing between Dr. Greene and the Franks.

I prepare a list of questions to discuss with Dr. Greene: What are the facts that we know for certain surrounding Joey's death? Who do you feel should be involved in the disclosure conversation? What should be disclosed? Who discloses the error? Where should the meeting be held? If an apology is appropriate, who should apologize? What does an appropriate apology look like to you? How may I assist during the meeting with the Franks?

I know that here will be two separate components to the meeting: disclosing the medical error and an appropriate apology. Without properly framing the information the Franks will need to receive regarding their son's death, future discussions surrounding what could have been done and what the physicians and hospital are doing to prevent something like this from happening again will not occur. Therefore, it is critical that each component holds equal importance, and adequate consideration and preparation need to occur prior to the meeting. Once we determine who should be involved in the disclosure conversation, I will need to reach out to each individual and offer to meet separately and collectively as we prepare to meet with the Franks.

Dr. Greene arrives at my office a few minutes early. He shares with me the clinical facts he is prepared to disclose to the Franks regarding the medical error and asks for assistance in framing the disclosure. As a designated neutral, I stress the importance in only sharing the facts, without speculation, to avoid future misunderstandings. I also realize that this is extremely difficult for Dr. Greene, as Joey's death is a distressing loss for him as well as the parents. Having to sit across from Mr. and Mrs. Frank and share with them that their son's death might have been prevented seems unbearable to Dr. Greene, and I know it will take an emotional toll on him and everyone involved.

We pause to talk about Joey. As Dr. Greene begins, his compassion and caring for his patient is clear. I realize that what I am seeing is what the parents need to see, that the tragic death of Joey Franks is shared by everyone involved in his clinical care. The physicians and hospital share in the Franks' need to understand what happened, why it happened, and — most importantly — what can be done to prevent it from ever happening again. As I wrap up my meeting with Dr. Greene, I assure him that I will reach out to the Franks and share with them that there is additional information and arrange for a meeting. I advise Dr. Greene that I will be offering assistance to the Franks in preparation for the meeting and explain that the Franks will need an understanding of the purpose of the meeting and who will be attending, as well as an opportunity to prepare any additional questions they may have. Dr. Greene agrees to contact me if there is any additional information, and I assure him I will notify him once I speak with the Franks.

Mrs. Franks is out when I call their home. I ask Mr. Franks if he would like me to call back when they are both available, and he says he will let Mrs. Franks know that I called. I inquire how they are both doing and if he has a moment to speak with me. "It is still extremely difficult, and we have so many questions; we still don't understand why Joey died," he says sadly. Without prolonging Mr. Frank's uncertainty that they may never receive answers to their questions, I explain that I have met with Dr. Greene and would like to arrange a meeting in order to discuss additional information. He is quiet for several seconds and then very softly says, "Oh." Deafening silence. "I see." A short pause, and then he says, "When would Dr. Greene like to meet with us?" I say that I would like to arrange a time that would be convenient for both he and his wife and ask if I could offer assistance in helping prepare questions they may have. We agree that I will call back the next evening to arrange a time for the three of us to speak and allow me the opportunity to assist in understanding what to expect at the meeting.

When I call the next evening, Mrs. Frank answers on the first ring and asks her husband to pick up the extension. They are anxious to hear any news regarding their son's death. I tell them that Dr. Greene has additional information and would like to meet, and he would like to obtain their permission to include any other physicians that might provide additional information and insight. I do not share any of the facts and advise that my role is to assist in helping prepare for and to facilitate the meeting itself. Mrs. Franks is quick to admit that she has an extensive list of questions and asks if I would share them all with Dr. Greene so he can address them when they meet. We set up a time to review the list, and I acknowledge how difficult this time must be for them, again offering my services if there is anything else I can do to be of assistance.

My separate meetings with Dr. Greene, Chief of Anesthesia Dr. Miller, and the Franks, were challenging yet fruitful. On the day of the scheduled joint meeting, I arrive early to prepare the room and greet everyone. As expected, emotions are high and tears are close to the surface. It is the first time the Franks have seen Dr. Greene since Joey's funeral. They stand across from each other, and it appears as if they don't know whether to shake hands or hug one another. Dr. Greene extends his hand to the Franks and quietly says, "Hello," before we move into the meeting room. Once seated, I thank everyone for their willingness to meet today and introduce everyone, including Dr. Miller. I explain that Dr. Greene has asked Dr. Miller to meet with us today since he will be able to answer questions relating to the anesthesia services Joey received during surgery. As Dr. Miller offers his sincere condolences for their loss, Mrs. Frank pauses briefly, reaches into her purse and pulls something out. As tears begin to slowly roll down her cheeks, she gently caresses the picture in the silver frame as she touches her fingers to her lips and places a kiss on the picture of Joey. "It is one of our last pictures of him. He hated that outfit, but I thought he looked handsome in it." She hands the photo to Dr. Miller as she whispers, "This is my son, Joey."

Dr. Greene looks at me for encouragement and I nod slightly. In prior discussions held with both physicians in preparation for this meeting, we made the decision that in light of the lengthy relationship Dr. Greene had established providing Joey's medical care, he would be the one to disclose the facts surrounding the medical error. Dr. Greene begins by thanking Mr. and Mrs. Frank for their willingness to meet with him and Dr. Miller. "I reviewed the questions you prepared and would like to address each one individually. Please stop me at any time if you have any questions about what I am saying or if I need to provide more information." The Franks agree and express their eagerness to know what happened.

Dr. Greene starts the dialogue at the beginning of the admission and slowly, patiently, and compassionately begins to outline each step of the care provided to Joey prior to the surgery. He pauses to check for their understanding and continues when the Franks nod that they understand and it is all right to continue. Dr. Greene glances at Dr. Miller before going further, as he is about to share with the Franks the events leading up to the anesthesia error, which ultimately led to Joey's death. As Dr. Greene shares the facts, he pauses several times to allow the Franks time to process the information being shared with them and then asks if they have any questions that either he or Dr. Miller could answer. At first, the Franks are silent. As the realization of what has been shared with them begins to show on their faces, the questions begin to flow. As Dr. Greene promised, he answers each question the Franks have honestly and compassionately. When Mrs. Franks asks Dr. Miller a question he does not have an answer for, he offers assurances the he will investigate further and asks permission to provide them with the information as it becomes available.

As my eyes are drawn to the picture of Joey, I sense the exhaustion of everyone in the room. The physicians have just shared with the Franks that their son's death was caused by a preventable error. The Franks have received a sincere apology accepting responsibility for what has happened. Questions have been asked by the Franks and they now need time to process all the information they have received. The room is quiet. Realizing that the disclosure of the error and the apology offered by Dr. Greene and Dr. Miller is only the beginning of what will be the focus of many future conversations, I take advantage of the pause in the conversation to ask if it would be OK if I 'checked in' with everyone over the next few days. I offer the suggestion that Mr. and Mrs. Frank might want to take some time to process what has been shared with them and to possibly meet again for further discussions as needed. As Mr. and Mrs. Frank rise to leave, they thank Dr. Greene and Dr. Miller for their honesty and concern. Mrs. Franks closes by saying, "We now know what happened and how it happened — I'd like to learn what could have been done to prevent such a mistake, and what you and the hospital will do to prevent it from happening to anyone else's little boy." Dr. Miller responds by explaining the root cause analysis process that is currently being conducted by the hospital's risk management department as well as the peer review process that is looking into the medical error. "As we discover more about what happened, we will share with you what we can, and want you to know that we are committed to providing a safe environment for all our patients. We know that mistakes have been made. We also know that transparency and a critical examination of what is not working well is necessary to assure patient safety in the future."