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.

JM Davies MSc MD FRCPC FRAeS
Professor Davies is a member of the Department of Anesthesiology, Perioperative & Pain Medicine at the Cumming School of Medicine, and an Adjunct Professor of Psychology, Faculty of Arts, University of Calgary. She is a member of W21C, a healthcare systems research and innovation initiative based in the University of Calgary’s Obrien Institute for Public Health. She holds Administrative Privileges in the Calgary Zone of Alberta Health Services. She has a BSc from the University of British Columbia and an MSc from the University of Alberta. After completing medical school at the University of Calgary and anaesthetic residency at Dalhousie University, she was a Clinical Fellow at Dalhousie, before undertaking a Killam Foundation Fellowship in fetal and maternal cardiovascular physiology at the University of Manitoba. She then returned to the University of Calgary to pursue her academic career. Since 1983 she has undertaken research in system safety, in both healthcare and aviation. Her current research includes refinement of investigation methodologies for personnel performance review and for system safety, Human Factors analysis of medical devices and healthcare environments, integration of quality and safety management, analysis of High Reliability Organizations, and aviation crash survivability of passengers and crew. She is a Fellow of the Royal Aeronautical Society.

Carmella L Steinke RRT BHS (RT) MPA CHE
Carmella originally trained and worked clinically as a Respiratory Therapist, before transitioning into a career of quality improvement and patient safety. She is currently the Executive Director for Integrated Quality Management in AHS (Calgary Zone). Prior to this role, she held numerous leadership roles in patient safety, quality improvement, and patient-family centered care at the Health Quality Council of Alberta, the University of Calgary, and the former Calgary Health Region. Carmella has led numerous patient safety reviews at an individual patient(s) level, as well as at a large, provincial level, that include both reactive and proactive approaches. Carmella has a Diploma in Respiratory Therapy, a Bachelor of Health Sciences (Respiratory Therapy), a Masters of Public Administration, and is also a Certified Health Executive with the Canadian College of Health Leaders.

W. Ward Flemons MD FRCPC
Professor Flemons is a member of the Department of Medicine where he serves as Vice-Chair, Health Analytics and Safety. He is the Quality and Safety Education lead for W21C, a healthcare systems research and innovation initiative based in the University of Calgary’s O’Brien Institute for Public Health. He is the Section Head of Respiratory Medicine for the Calgary Zone of Alberta Health Services and the Cumming School of Medicine, University of Calgary. After obtaining his BMSc and MD degree from the University of Alberta, Ward qualified in Internal Medicine and then Respiratory Medicine through the Royal College of Physicians and Surgeons of Canada in 1889 and 1990, respectively. He completed a three-year Alberta Heritage Foundation for Medical Research Clinical Fellowship, publishing several articles and book chapters in his field of study, sleep apnea. Dr. Flemons went on to become the first Quality Improvement clinician for the Department of Medicine in 2000 and was then promoted in 2001 to lead Quality Improvement and Health Information for the entire Calgary Health Region. Following the tragic death of two patients as a result of drug substitution errors, he was appointed Vice-President of Quality, Safety and Health Information in 2004. In 2009 he returned to the Faculty of Medicine at the University of Calgary as a Professor affiliated with the W21C and leading a highly successful Quality and Safety Continuing Medical Education course for the Faculty. He became a Medical Director with the Health Quality Council of Alberta and in that capacity developed several Quality and Safety frameworks, including its information on Just Culture (https: //justculture.hqca.ca/).

Ward also led and participated in several large reviews of Alberta’s healthcare system. Between 2008 and 2012 he was a member of the Canadian Patient Safety Institute’s (CPSI) Board of Directors. Since the CPSI’s inception in 2004, Ward has worked closely with the organization and participated in many of its educational initiatives and the development of its guidance documents. He has also worked with many families who have experienced the loss of a loved one as the result of adverse events. In 2017 he worked closely with the Price family to help create the highly acclaimed film, Falling Through the Cracks: Greg’s Story (https: //gregswings.ca/fttc-gregsstory/).