ABSTRACT
In Calgary in 2004 two patients died unexpectedly from excess potassium chloride in pharmacy-prepared dialysate. Internal and external safety reviews produced 121 individual recommendations. The deaths and reviews provided a safety ‘wake-up call’ and an opportunity to re-examine the Region’s safety practices and procedures. Since then, many changes have been undertaken, starting with top management’s recognition that safety was not identified as a unique priority. The Region has created a patient safety framework (like a safety management system), started to recognize the tensions between various aspects of care (such as access and safety), and developed and implemented new policies (for reporting, disclosing, informing, and a just and trusting culture). Rather than specifying a ‘no-blame’ culture, the Region has chosen to emphasize responsibility and accountability. Taken together, all these changes are helping to move the Region along the trajectory of a safety culture, in the hope of providing safer patient care.
