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001 9781003185307
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008 220401s2022 xx o 000 0 eng d
040 _aOCoLC-P
_beng
_erda
_epn
_cOCoLC-P
020 _a9781003185307
_q(electronic bk.)
020 _a1003185304
_q(electronic bk.)
020 _a9781000577037
_q(electronic bk. ;
_qPDF)
020 _a1000577031
_q(electronic bk. ;
_qPDF)
020 _a9781000577044
_q(electronic bk. ;
_qEPUB)
020 _a100057704X
_q(electronic bk. ;
_qEPUB)
020 _z9781032028132
020 _z9781032028088
024 7 _a10.4324/9781003185307
_2doi
035 _a(OCoLC)1308514301
035 _a(OCoLC-P)1308514301
050 4 _aRA395.C2
072 7 _aBUS
_x070170
_2bisacsh
072 7 _aBUS
_x071000
_2bisacsh
072 7 _aBUS
_x097000
_2bisacsh
072 7 _aMBP
_2bicssc
082 0 4 _a362.10971
_223
100 1 _aDavies, Jan M.
245 1 0 _aFatal solution :
_bhow a healthcare system used tragedy to transform itself and redefine just culture /
_cJan M. Davies, Carmella Steinke, W. Ward Flemons.
250 _aFirst edition.
264 1 _a[Place of publication not identified] :
_bProductivity Press,
_c2022.
300 _a1 online resource (xxx, 244 pages)
336 _atext
_btxt
_2rdacontent
337 _acomputer
_bc
_2rdamedia
338 _aonline resource
_bcr
_2rdacarrier
505 0 _aChapter 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 _aOne 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 _aOCLC-licensed vendor bibliographic record.
650 0 _aMedical errors
_zCanada.
650 0 _aMedical care
_zCanada
_xSafety measures.
650 0 _aHealth services administration
_zCanada.
650 7 _aBUSINESS & ECONOMICS
_xLeadership.
_2bisacsh
650 7 _aBUSINESS & ECONOMICS
_xWorkplace Culture.
_2bisacsh
650 7 _aBUSINESS & ECONOMICS / Leadership
_2bisacsh
650 7 _aBUSINESS & ECONOMICS / Workplace Culture
_2bisacsh
700 1 _aSteinke, Carmella.
700 1 _aFlemons, W. Ward.
856 4 0 _3Taylor & Francis
_uhttps://www.taylorfrancis.com/books/e/9781003185307
856 4 0 _3Taylor & Francis
_uhttps://www.taylorfrancis.com/books/9781003185307
856 4 2 _3OCLC metadata license agreement
_uhttp://www.oclc.org/content/dam/oclc/forms/terms/vbrl-201703.pdf
999 _c4986
_d4986