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



