Fatal solution : (Record no. 4986)
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| 000 -LEADER | |
|---|---|
| fixed length control field | 04468cam a2200601 i 4500 |
| 001 - CONTROL NUMBER | |
| control field | 9781003185307 |
| 003 - CONTROL NUMBER IDENTIFIER | |
| control field | FlBoTFG |
| 005 - DATE AND TIME OF LATEST TRANSACTION | |
| control field | 20240213122826.0 |
| 006 - FIXED-LENGTH DATA ELEMENTS--ADDITIONAL MATERIAL CHARACTERISTICS | |
| fixed length control field | m o d |
| 007 - PHYSICAL DESCRIPTION FIXED FIELD--GENERAL INFORMATION | |
| fixed length control field | cr cnu|||unuuu |
| 008 - FIXED-LENGTH DATA ELEMENTS--GENERAL INFORMATION | |
| fixed length control field | 220401s2022 xx o 000 0 eng d |
| 040 ## - CATALOGING SOURCE | |
| Original cataloging agency | OCoLC-P |
| Language of cataloging | eng |
| Description conventions | rda |
| -- | pn |
| Transcribing agency | OCoLC-P |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 9781003185307 |
| Qualifying information | (electronic bk.) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 1003185304 |
| Qualifying information | (electronic bk.) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 9781000577037 |
| Qualifying information | (electronic bk. ; |
| -- | PDF) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 1000577031 |
| Qualifying information | (electronic bk. ; |
| -- | PDF) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 9781000577044 |
| Qualifying information | (electronic bk. ; |
| -- | EPUB) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| International Standard Book Number | 100057704X |
| Qualifying information | (electronic bk. ; |
| -- | EPUB) |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| Canceled/invalid ISBN | 9781032028132 |
| 020 ## - INTERNATIONAL STANDARD BOOK NUMBER | |
| Canceled/invalid ISBN | 9781032028088 |
| 024 7# - OTHER STANDARD IDENTIFIER | |
| Standard number or code | 10.4324/9781003185307 |
| Source of number or code | doi |
| 035 ## - SYSTEM CONTROL NUMBER | |
| System control number | (OCoLC)1308514301 |
| 035 ## - SYSTEM CONTROL NUMBER | |
| System control number | (OCoLC-P)1308514301 |
| 050 #4 - LIBRARY OF CONGRESS CALL NUMBER | |
| Classification number | RA395.C2 |
| 072 #7 - SUBJECT CATEGORY CODE | |
| Subject category code | BUS |
| Subject category code subdivision | 070170 |
| Source | bisacsh |
| 072 #7 - SUBJECT CATEGORY CODE | |
| Subject category code | BUS |
| Subject category code subdivision | 071000 |
| Source | bisacsh |
| 072 #7 - SUBJECT CATEGORY CODE | |
| Subject category code | BUS |
| Subject category code subdivision | 097000 |
| Source | bisacsh |
| 072 #7 - SUBJECT CATEGORY CODE | |
| Subject category code | MBP |
| Source | bicssc |
| 082 04 - DEWEY DECIMAL CLASSIFICATION NUMBER | |
| Classification number | 362.10971 |
| Edition number | 23 |
| 100 1# - MAIN ENTRY--PERSONAL NAME | |
| Personal name | Davies, Jan M. |
| 245 10 - TITLE STATEMENT | |
| Title | Fatal solution : |
| Remainder of title | how a healthcare system used tragedy to transform itself and redefine just culture / |
| Statement of responsibility, etc. | Jan M. Davies, Carmella Steinke, W. Ward Flemons. |
| 250 ## - EDITION STATEMENT | |
| Edition statement | First edition. |
| 264 #1 - PRODUCTION, PUBLICATION, DISTRIBUTION, MANUFACTURE, AND COPYRIGHT NOTICE | |
| Place of production, publication, distribution, manufacture | [Place of publication not identified] : |
| Name of producer, publisher, distributor, manufacturer | Productivity Press, |
| Date of production, publication, distribution, manufacture, or copyright notice | 2022. |
| 300 ## - PHYSICAL DESCRIPTION | |
| Extent | 1 online resource (xxx, 244 pages) |
| 336 ## - CONTENT TYPE | |
| Content type term | text |
| Content type code | txt |
| Source | rdacontent |
| 337 ## - MEDIA TYPE | |
| Media type term | computer |
| Media type code | c |
| Source | rdamedia |
| 338 ## - CARRIER TYPE | |
| Carrier type term | online resource |
| Carrier type code | cr |
| Source | rdacarrier |
| 505 0# - FORMATTED CONTENTS NOTE | |
| Formatted contents note | Chapter 1: "Two patients are dead and Foothills Hospital staff are to blame." BlameChapter 2: "And she died because of one of the most dreadful medical mistakes ever revealed in Alberta, or all of Canada." From memory and information processing to errors, violations and sabotageChapter 3: "Don't make me sue you." Apology, disclosure and supportChapter 4: "All Intensive Care Units in Calgary were notified to look out for similar difficulties."It's mainly about sharing information Chapter 5: "But what are we going to do? Hang a pharmacist?" Supporting healthcare providersChapter 6: "It is vital we learn from these mistakes." Systems, systems thinking and investigatingChapter 7: "Get something positive out of this tragedy." The Region's patient safety strategyChapter 8: "A major shake-up" The journey never endsAfterword #1 -- Jack Davis MScAfterword #2 -- Deborah E Prowse QC |
| 520 ## - SUMMARY, ETC. | |
| Summary, etc. | 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. |
| 588 ## - SOURCE OF DESCRIPTION NOTE | |
| Source of description note | OCLC-licensed vendor bibliographic record. |
| 650 #0 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | Medical errors |
| Geographic subdivision | Canada. |
| 650 #0 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | Medical care |
| Geographic subdivision | Canada |
| General subdivision | Safety measures. |
| 650 #0 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | Health services administration |
| Geographic subdivision | Canada. |
| 650 #7 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | BUSINESS & ECONOMICS |
| General subdivision | Leadership. |
| Source of heading or term | bisacsh |
| 650 #7 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | BUSINESS & ECONOMICS |
| General subdivision | Workplace Culture. |
| Source of heading or term | bisacsh |
| 650 #7 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | BUSINESS & ECONOMICS / Leadership |
| Source of heading or term | bisacsh |
| 650 #7 - SUBJECT ADDED ENTRY--TOPICAL TERM | |
| Topical term or geographic name entry element | BUSINESS & ECONOMICS / Workplace Culture |
| Source of heading or term | bisacsh |
| 700 1# - ADDED ENTRY--PERSONAL NAME | |
| Personal name | Steinke, Carmella. |
| 700 1# - ADDED ENTRY--PERSONAL NAME | |
| Personal name | Flemons, W. Ward. |
| 856 40 - ELECTRONIC LOCATION AND ACCESS | |
| Materials specified | Taylor & Francis |
| Uniform Resource Identifier | <a href="https://www.taylorfrancis.com/books/e/9781003185307">https://www.taylorfrancis.com/books/e/9781003185307</a> |
| 856 40 - ELECTRONIC LOCATION AND ACCESS | |
| Materials specified | Taylor & Francis |
| Uniform Resource Identifier | <a href="https://www.taylorfrancis.com/books/9781003185307">https://www.taylorfrancis.com/books/9781003185307</a> |
| 856 42 - ELECTRONIC LOCATION AND ACCESS | |
| Materials specified | OCLC metadata license agreement |
| Uniform Resource Identifier | <a href="http://www.oclc.org/content/dam/oclc/forms/terms/vbrl-201703.pdf">http://www.oclc.org/content/dam/oclc/forms/terms/vbrl-201703.pdf</a> |
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