Our virtual seminar looked at Just Culture and Incident Investigation and featured two of the authors, Jan Davies and Carmella Steinke, of the new book ‘Fatal Solution’ , a book which describes “how a healthcare system used tragedy to transform itself and redefine Just Culture”.
Fatal Solution Book summary
- “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 traveled 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.”
To accompany this story we were joined by Ken Catchpole, Professor of Human Factors at Medical University of South Carolina who discussed a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This illustrated the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He also commented on the recent RaDonda Vaught case, and what that tells us about how far we still have to go.
We were joined by Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds who looked at how you involve patients and families in serious incident investigations, together with a session run by Dr Clare Crowley, National Investigator at HSIB providing a view from a pharmacy perspective.
Programme (GMT UK time zone):
14.00 – Welcome
14.10 – Jan Davies, University of Calgary and Carmella Steinke, Alberta Health Services – Authors of Fatal Solution
14.50 – Q & A on the Canadian case
15.20 – Break
15.30 – Prof. Jane O’Hara, Health and Quality Safety, Leeds University
16.00 – Prof. Ken Catchpole, Prof. Human Factors, Medical University South Carolina
16.30 – Dr Clare Crowley, National Investigator HSIB and Pharmacist
17.00 – Q & A with speakers
17.30 – Closing remarks
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