Written from the perspective of a risk manager, the author tells the story of a medication administration error that led to the death of a 7-year-old boy. Without focusing on the details of the error, the author describes the investigative process that uncovered it, the careful attention paid to communication with the bereaved parents, and the administrative steps taken subsequently to reduce the risk of similar events. The author describes a collaborative, mutually supportive, systems-oriented approach to safety in place at her institution, crediting this approach with a favorable resolution to a tragic incident. This story is also discussed in the video Beyond Blame.