ABSTRACT
This chapter addresses several challenging issues, to help one's understanding of how and why challenging situations arise. It explores strategies that can be used to deal with them, as well as the steps that can be taken to prevent or reduce their reoccurrence. In 2006, the Healthcare Commission reported on the findings of an investigation into the many deaths at Stoke Mandeville Hospital in Buckinghamshire resulting from two outbreaks of Clostridium difficile infection. The infection control team tried unsuccessfully, during both outbreaks, to gain a dedicated area for patients withC. difficile. A study of the link between leadership and safety outcomes in hospitals found that, among 200 health professionals, quality relationships based on fairness and empathy play a pivotal role in creating positive safety climates and work environments. Errors detected by chance can lead to system changes in an environment that promotes safety.
