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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.
Jan M. Davies MD MSc FRCPC; Carmella Steinke, RRT, BHS(RT), MPA; W. Flemons, MD, FRCPC
Chapter 1: "Two patients are dead and Foothills Hospital staff are to blame." Chapter 2: "And she died because of one of the most dreadful medical mistakes ever revealed in Alberta, or all of Canada." Chapter 3: "Don't make me sue you." Chapter 4: "All Intensive Care Units in Calgary were notified to look out for similar difficulties." Chapter 5: "But what are we going to do? Hang a pharmacist?" Chapter 6: "It is vital we learn from these mistakes." Chapter 7: "Get something positive out of this tragedy." Chapter 8: "A major shake-up." Afterword #1 - Jack Davis MSc Afterword #2 - Deborah E Prowse QC
