In 1995, a 7-year-old boy died when he was injected with what was later discovered to be the wrong medication during routine, elective ear surgery. While this case is remembered for many reasons, most especially for the tragic and unnecessary loss of the young boy's life, it is also remembered within the health care community for the organization's--Martin Memorial Medical Center in Stuart, FL--immediate response and openness in sharing with the boy's family and, later, other health care organizations, the steps taken following the event to prevent such medication administration errors from occurring in the future.