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

275 Pages·2022·2.809 MB·English

by  Jan M Davies, Carmella Steinke, W Ward Flemons

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.
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