Fatal Solution: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture
Jan M. Davies, MSc, MD, FRCPC, FRAeS · Carmella Steinke, RRT, BHS(RT), MPA · W. Ward Flemons, MD, FRCPC
May 2022 · CRC Press
Ebook
274
Pages
family_home
Eligible
info
About this ebook
One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More ...
Discover more
About the author
Jan M. Davies MD MSc FRCPC; Carmella Steinke, RRT, BHS(RT), MPA; W. Flemons, MD, FRCPC
Jan M. Davies MD MSc FRCPC; Carmella Steinke, RRT, BHS(RT), MPA; W. Flemons, MD, FRCPC
Rate this ebook
Tell us what you think.
Reading information
Smartphones and tablets
Install the Google Play Books app for Android and iPad/iPhone. It syncs automatically with your account and allows you to read online or offline wherever you are.
Laptops and computers
You can listen to audiobooks purchased on Google Play using your computer's web browser.
eReaders and other devices
To read on e-ink devices like Kobo eReaders, you'll need to download a file and transfer it to your device. Follow the detailed Help Center instructions to transfer the files to supported eReaders.
