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Fatal Solution - How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture (Paperback)
Loot Price: R1,068
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Fatal Solution - How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture (Paperback)
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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.
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