Fatal Solution How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture

"One of the best accident analysis books I have read. The authors' clinical expertise is effectively blended with an understanding of the psychological and organizational factors that create conditions for adverse events. Their first-hand experiences of the aftermath create a powerful account of the cultural shift that was achieved. Highly recommended reading for those striving to improve patient safety."

Rhona Flin PhD, FBPsS, FRSE,Professor of Industrial Psychology

Aberdeen Business School, Robert Gordon University, Aberdeen

"Jan Davies, Carmella Steinke & Ward Flemons describe the many facets of a tragedy and use it to tell the story of patient safety and illuminate the role that Just Culture plays in keeping patients safe and responding humanely when harm occurs. Stories, science and practice seamlessly interwoven in a fascinating narrative."

Charles Vincent PhD, Professor of Psychology, University of Oxford

"One of the strengths of this book is to report clinical dramas in all their human dimension and to speak of a global story in which we understand the deep distress of all parties - patients, families, professionals and institutions. The book delivers to us, with the art of speaking simply of complex things, a series of keys to cognitive functioning. These are just as much the engine of success in most cases, thanks to brilliant heuristics, as they are the rare source of dramas. Suddenly, the question of blame, learning culture, transparency and saying sorry can be reread differently, not so as to evade the problem, but to remain coherent and useful for all parties."

René Amalberti MD PhD, Directeur & Professeur de Médecine

FONCSI, Toulouse, France

"In this excellent book, the authors have made brilliant use of the stories of two patients to link everything together, and to illustrate the ground-breaking work done in Calgary. What a model for others to follow!"

Dr. Rod Westhorpe OAM FRCA FANZCA, Past President, Australian Society of Anaesthetists

Founding and Life Member, Australian Patient Safety Foundation, Melbourne, Australia