Fatal Solution: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture PDF
Preview Fatal Solution: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture
Endorsements One of the best accident analysis books I have read. The authors’ clinical expertise is effectively blended with an understanding of the psychological and organiza- tional 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 are 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 dis- tress 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 Fatal Solution 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 MPA, and W. Ward Flemons MD FRCPC First published 2022 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 Jan M Davies, Carmella Steinke & W Ward Flemons The right of Jan M Davies, Carmella Steinke & W Ward Flemons to be identified as author of this work has been asserted by her/him/they in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, i ncluding photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. ISBN: 9781032028132 (hbk) ISBN: 9781032028088 (pbk) ISBN: 9781003185307 (ebk) DOI: 10.4324/9781003185307 Typeset in Garamond by codeMantra Dedication This book is dedicated to the two families at the center of this tragedy and to all patients, their families and friends, who have been harmed in the course of receiving healthcare. We also dedicate this book to healthcare providers and leaders who have suffered psychological harm from their involvement in an event in which a patient was harmed. Epigram Systems awareness and systems design are important for health pro- fessionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a sys- tem’s success. Ultimately, the secret of quality is love. Avedis Donabedian (1919–2000) Donabedian A. 2001. Interview: A founder of Quality Assessment encounters a troubled system firsthand. Fitzhugh Mullan Health Affairs 2001; 20:1137–141. doi:10.1377/hlthaff.20.1.137. vii
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