"Fix it as best you can, and learn from your mistakes": apology lessons, past and present.

"In the moment, you know what the right thing is; just do what your mother taught you to do." -From my address at the annual Medically Induced Trauma Support Services dinner, October 2011 In November of 2009, 1 walked into a room to meet the brother of a man who died in our emergency room, a brother who on behalf of his family was vigorously pursuing a resolution in the courts. There was no policy to follow. There was no planning with the legal team or public relations to script the key messages for the meeting. As a new CEO, I had no prior experience to draw from. The words that I spoke came from what my mother had taught me. I said, "I am so sorry for what happened to your brother." This case and the experience of Kent Hospital provide an opportunity to view the impact of disclosure and apology on an institution in the moment and in the years that follow. To learn from what was done well and also from what was not, we must first look back at the events of 2006. THE CASE OF MICHAEL J. WOODS In 2006, Michael J. Woods, 49, arrived at the Kent Hospital emergency department complaining of a severe sore throat. He died of cardiac arrest several hours later. Although a physician had ordered cardiac monitoring, Michael was not placed on cardiac monitoring during his time in the emergency room. Upon returning from an imaging study, Michael, still on his stretcher, was placed in the hallway near the nurses' station, as his treatment bay had been given to another patient. He suffered a heart attack and became unresponsive while in the hallway. He could not be resuscitated. Michael was active in our community and had run twice for mayor. He had three children, and his family had frequented Kent in the past. A malpractice case was brought on behalf of the estate by Michael's only brother, James Woods, the TV and movie star. The trial began in November 2009, and for three weeks our hospital and the case of Michael J. Woods were front-page news (Coletta 2010). Many of the hospital staff had grown up with the Woods brothers and knew the family well. I believe that an assumed or real familiarity with those affected by medical error raises the risk of bias in an institution's or caregiver's response. That bias may affect the situation in a variety of ways - sometimes causing the institution to minimize the issue, in other cases to overreact to it. In this instance, the hospital did not recognize the degree of seriousness that Michael's case represented or his family's resolve to seek justice. Critics have questioned the apology and resolution to the Woods case, wondering whether the result would have been the same if there had been no celebrity involved, no media attention. The answer to the question is, sadly, no. The result would likely have been very different. The injured party may not have had the resources to proceed to court, and, more significant, as CEO I likely would not have been as aware without the public aspect of the case. AU patients and their loved ones are entitled to the same treatment when things don't go as planned, whether they are angry or withdrawn, rich or poor, aware or not. THE EXECUTIVE CHAMPION In the features, Leape and Boothman, Imhoff, and Campbell cite the need for executive champions to change the organization's approach to dealing with situations when unexpected outcomes occur. In almost every aspect of a complex organization, issues are resolved at the lowest level possible and the CEO is "bothered" with problems only when necessary. "Don't bring me problems; bring me solutions" is a common CEO missive. However, an environment supportive of transparency and disclosure requires that the CEO be kept actively aware of issues as they arise. CEOs must make it clear that they are available when issues are identified. Many people gave us acclaim for the resolution of the Woods case, but rather than being a hallmark of our culture at the time, the situation is in fact more reflective of the failure of a system that did not respond in an appropriate and timely manner. …