Email Updates
Book/Report
Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture.
October 5, 2022
Davies JM, Steinke C, Flemons WW. New York, NY: Productivity Press; 2022. ISBN: 9781032028132.
Look-alike packaging can contribute to patient harm. This book examines how a mix up involving potassium chloride resulted in the deaths of two patients. The Canadian organization involved applied Reason’s strategies to work past blame to examine the events and consider how just culture can be entrenched organization-wide to improve safety for patients, families, and those who care for them.
