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One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking.

Inspired to share the lessons from a medical drug mix-up that resulted in tragedy, three UCalgary professors collaborated on a book examining what went wrong and how the tragedy sparked a transformation in the years that followed.

Fatal Solution: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture highlights the story of two critically ill patients who were accidentally exposed to an incorrect dialysate solution compounded in Calgary in 2004 and the aftermath that led to changes in the health care system.

“It’s important to keep the memory and the lessons learned alive following such a tragedy,” says Dr. Jan Davies, MD, a Faculty of Arts and Cumming School of Medicine (CSM) professor and patient safety expert. “We’ve tried to put those lessons into a book about how organizations respond in the wake of tragedy, about the transformation that occurs.”

The patients, who had suffered acute kidney failure, were dialyzed with a solution containing potassium chloride instead of sodium chloride. Potassium chloride is lethal when the body’s level increases rapidly; sodium chloride is commonly administered to patients intravenously to treat fluid loss or increase salt levels.

Davies, along with her co-authors, Dr. Ward Flemons, MD, a professor in the Department of Medicine and Carmella Steinke, an adjunct lecturer in the Department of Medicine, played a central role in the years that followed the tragedy, helping to lead organizational transformation in the former Calgary Health Region. All three used the lessons learned for courses they developed on patient safety, particularly for courses that taught about investigations into healthcare events like this. The courses used Davies’ methodology called Systematic Systems Analysis.

“As we went about keeping these lessons at the forefront, we came to realize that this story needed to be in a book, and much more broadly available to learners and the public. We felt like this was something that needed to be done to expand its reach,” says Davies.

The book is a mix of recollections of the tragic events in 2004 and a deeper exploration of academic theory related to the principles of just culture in health care. It includes a theory championed by renowned patient safety expert, Dr. James Reason, PhD, a professor emeritus at the University of Manchester. He wrote about the principles of error management in his 1997 book, Managing the Risks of Organizational Accidents.

“We believe it’s important to talk about an event that cannot be forgotten or hidden. That people are ultimately better served by seeking the lessons from past mistakes,” says Flemons.

He says this includes ensuring that blame is not transferred to individuals but rather, after thorough investigation, necessary shifts in culture occur that enhance safety; that organizations reach out to families to grieve together and offer opportunities to participate in the organization’s process of improvement; that individuals involved in the specific incident are supported through any guilt or shame they may experience in the aftermath.  

The book includes a powerful Afterword written by a family member of one of the patients who died. The authors say the book should be read not only by healthcare managers but also by medical students, healthcare providers, people in health care leadership, patients, and the public.

Learners in CSM’s Precision Health Program, Quality and Safety specialization, are each being provided with a copy of the book courtesy of the program. The book will be released for sale on May 11 at bookstores throughout Canada the United States and the UK. .