FATAL SOLUTION : how a healthcare system used tragedy to transform itself and redefine just... 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 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. 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. Cover 1 Half Title 4 Title Page 6 Copyright Page 7 Dedication 8 Table of Contents 12 Foreword 16 Acknowledgments 18 Preface 20 Introduction 24 A Guide to the Book 28 Prologue: February 28th–March 5th, 2004 32 1 “Two Patients Are Dead and Foothills Hospital Staff Are to Blame .” 50 Blame 56 The Human Tendency to Blame 56 Psychological Concepts Underlying Blame 58 The Path Model of Blame 67 Blame and the Media 68 The Blame Cycle 70 References 72 2 “And She Died Because of One of the Most Dreadful Medical Mistakes Ever Revealed in Alberta, or All of Canada.” 76 From Memory and Information Processing to Errors, Noncompliance and Willful Intent to Harm 80 Memory 80 Processing Information 85 Human Information Processing Frameworks and Errors 87 Noncompliance 96 Willful Intent to Harm 102 References 103 3 “Don’t Make Me Sue You.” 108 Apology, Disclosure, and Support 111 What Patients and Families Experience after a Patient Suffers Harm 112 What Patients Need and Expect 113 References 129 4 “All Intensive Care Units in Calgary Were Notified to Look Out for Similar Difficulties .” 132 It’s Mainly About Sharing Information 137 Types of Organizations 137 Informing 138 Vulnerable Organizations 141 Safety Culture 143 Reporting 144 The Original Just Culture 155 References 157 5 “But What Are We Going to Do? Hang a Pharmacist?” 162 Supporting Healthcare Providers 165 A Journey, Perhaps Toward Healing 165 Supporting Healthcare Providers 171 Fair Assessment 173 How Language and Beliefs Can Affect Healing 173 References 176 6 “It Is Vital We Learn from These Mistakes .” 180 Systems, Systems Thinking and Investigating 183 Systems 183 Investigating in Healthcare 191 When the Line Has Been Crossed 199 References 205 7 “Get Something Positive Out of This Tragedy.” 210 The Region’s Patient Safety Strategy 218 Organizational Structure 221 Resources 222 Culture 224 Leadership and Accountability 226 Safety Management – Developing a Continuous Improvement Ethos 227 References 230 8 “A Major Shake-Up.” 234 The Journey Never Ends 244 Making Changes 245 Just Culture: Broadly Speaking 249 Just Culture: Future Direction 254 An Opportunity Not Lost 255 References 257 Afterword 1 260 Afterword 2 264 Index 268 Just,Culture,in,healthcare;,Medication,errors;,Learning,from,tragedies;,Patient,safety;,Investigating,the,system;,Cognitive,Biases;,The,Person,Model;,The,Blame,Cycle;,Systematic,Systems,Analysis,(SSA);,Systematic,Individual,Assessment,(SIA);,responsibility;,Accountability Just Culture in healthcare,Medication errors,Learning from tragedies,Patient safety,Investigating the system,Cognitive Biases,The Person Model,The Blame Cycle,Systematic Systems Analysis (SSA),Systematic Individual Assessment (SIA),responsibility,Accountability