Overview

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 traveled 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.

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Carmella Steinke currently works in Alberta Health Services in a leadership role. She trained as a respiratory therapist and worked mainly in adult and neonatal Intensive Care Units until becoming involved in quality improvement efforts in neurosciences. Before the deaths, she was also chair of the Health Advisory Committee and in that capacity was involved with the Board of the Calgary Health Region. After the deaths and with creation of the new safety teams, Carm was offered the position of senior clinical safety leader. She then went on to become the manager of clinical safety evaluation. She oversaw the creation of the new reporting system, the setting up of the Clinical Safety Committees, and the hiring of those who supported them. In 2008, she transitioned into a new role in Alberta Health Services as the director of safety reporting. Kim Niemi has appeared on numerous stages in the Boston area as an actor and singer/songwriter, including Theater Lobby in the North End, Chevalier Theatre, Club Cafe, Club Passim, The Lizard Lounge, and The Burren. She sang lead vocals for popular New England country bands DiggerDawg and STAMPEDE (as Kim Davidson), opening for national acts like Charlie Daniels and Rodney Atkins. Kim is a graduate of the American Musical and Dramatic Academy and a proud member of Actors' Equity Association and SAG-AFTRA. Her voice has been described as soothing, soulful, and powerful. Kim Niemi has appeared on numerous stages in the Boston area as an actor and singer/songwriter, including Theater Lobby in the North End, Chevalier Theatre, Club Cafe, Club Passim, The Lizard Lounge, and The Burren. She sang lead vocals for popular New England country bands DiggerDawg and STAMPEDE (as Kim Davidson), opening for national acts like Charlie Daniels and Rodney Atkins. Kim is a graduate of the American Musical and Dramatic Academy and a proud member of Actors' Equity Association and SAG-AFTRA. Her voice has been described as soothing, soulful, and powerful.

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