1st Edition

Fatal Solution How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture

    274 Pages
    by Productivity Press

    274 Pages
    by Productivity Press

    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.

    Chapter 1: "Two patients are dead and Foothills Hospital staff are to blame." Blame

    Chapter 2: "And she died because of one of the most dreadful medical mistakes ever revealed in Alberta, or all of Canada." From memory and information processing to errors, violations and sabotage

    Chapter 3: "Don’t make me sue you." Apology, disclosure and support

    Chapter 4: "All Intensive Care Units in Calgary were notified to look out for similar difficulties."

    It’s mainly about sharing information

    Chapter 5: "But what are we going to do? Hang a pharmacist?" Supporting healthcare providers

    Chapter 6: "It is vital we learn from these mistakes." Systems, systems thinking and investigating

    Chapter 7: "Get something positive out of this tragedy." The Region’s patient safety strategy

    Chapter 8: "A major shake-up" The journey never ends


    Afterword #1 - Jack Davis MSc

    Afterword #2 - Deborah E Prowse QC


    Jan M. Davies MD MSc FRCPC; Carmella Steinke, RRT, BHS(RT), MPA; W. Flemons, MD, FRCPC

    "One of the best accident analysis books I have read. The authors' clinical expertise is effectively blended with an understanding of the psychological and organizational factors that create conditions for adverse events. Their first-hand experiences of the aftermath create a powerful account of the cultural shift that was achieved. Highly recommended reading for those striving to improve patient safety."

    Rhona Flin PhD, FBPsS, FRSE,Professor of Industrial Psychology

    Aberdeen Business School, Robert Gordon University, Aberdeen

    "Jan Davies, Carmella Steinke & Ward Flemons describe the many facets of a tragedy and use it to tell the story of patient safety and illuminate the role that Just Culture plays in keeping patients safe and responding humanely when harm occurs. Stories, science and practice seamlessly interwoven in a fascinating narrative."

    Charles Vincent PhD, Professor of Psychology, University of Oxford

    "One of the strengths of this book is to report clinical dramas in all their human dimension and to speak of a global story in which we understand the deep distress of all parties - patients, families, professionals and institutions. The book delivers to us, with the art of speaking simply of complex things, a series of keys to cognitive functioning. These are just as much the engine of success in most cases, thanks to brilliant heuristics, as they are the rare source of dramas. Suddenly, the question of blame, learning culture, transparency and saying sorry can be reread differently, not so as to evade the problem, but to remain coherent and useful for all parties."


    René Amalberti MD PhD, Directeur & Professeur de Médecine

    FONCSI, Toulouse, France

    "In this excellent book, the authors have made brilliant use of the stories of two patients to link everything together, and to illustrate the ground-breaking work done in Calgary. What a model for others to follow!"

    Dr. Rod Westhorpe OAM FRCA FANZCA, Past President, Australian Society of Anaesthetists

    Founding and Life Member, Australian Patient Safety Foundation, Melbourne, Australia