BEGIN:VCALENDAR
VERSION:2.0
PRODID:-//InvisionCommunity Events 4.7.23//EN
METHOD:PUBLISH
CALSCALE:GREGORIAN
REFRESH-INTERVAL:PT15M
X-PUBLISHED-TTL:PT15M
X-WR-CALNAME:Community Calendar
NAME:Community Calendar
BEGIN:VTIMEZONE
TZID:Europe/London
TZURL:http://tzurl.org/zoneinfo/Europe/London
X-LIC-LOCATION:Europe/London
BEGIN:DAYLIGHT
TZOFFSETFROM:+0000
TZOFFSETTO:+0100
TZNAME:BST
DTSTART:20220327T020000Z
RRULE:FREQ=YEARLY;BYMONTH=3;BYDAY=-1SU
END:DAYLIGHT
BEGIN:STANDARD
TZOFFSETFROM:+0100
TZOFFSETTO:+0000
TZNAME:GMT
DTSTART:20221030T020000Z
RRULE:FREQ=YEARLY;BYMONTH=10;BYDAY=-1SU
END:STANDARD
END:VTIMEZONE
BEGIN:VEVENT
SUMMARY:Just Culture and incident investigation
DTSTAMP:20220920T120642Z
SEQUENCE:0
UID:898-1-ee2a5ec9cbd1b5a75b4ec5d63ec903ec@www.pslhub.org
ORGANIZER;CN="Patient Safety Learning":noreply@pslhub.org
DESCRIPTION:\n	This virtual seminar from the Clinical Human Factors Grou
	p will be looking at Just Culture and incident investigation and will fea
	ture two of the authors\, Jan Davies and Carmella Steinke\, of the new boo
	k 'Fatal Solution' \, a book which describes \"how a healthcare system use
	d tragedy to transform itself and redefine Just Culture\".\n\n\n\n	In this
	 provocative true story of tragedy\, the authors recount the journey trave
	lled and what was learned by\, at the time\, Canada’s largest fully inte
	grated health region. They weave this story together with the theory about
	 why things fall apart and how to put them back together again. Building o
	n the writings and wisdom of James Reason and other experts\, the book exp
	lores new ways of thinking about Just Culture\, and what this would mean f
	or 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 a
	s it is about supporting a safety culture.\"\n\n\n\n	To accompany this sto
	ry Ken Catchpole\, Professor of Human Factors at Medical University of So
	uth Carolina will discuss a variety of enablers and barriers to learning f
	rom clinical safety incidents\, based on his perspective within the US hea
	lth system. This will illustrate the format of incident analysis and respo
	nse at MUSC\; legal and regulatory issues\; and the role and impact of hum
	an factors and systems engineering. He will also comment on the recent RaD
	onda Vaught case\, and what that tells us about how far we still have to g
	o.\n\n\n\n	Jane O’Hara\, Professor of Healthcare Quality and Safety in L
	eeds will adds a UK perspective to this worldwide issue\, together with a 
	session focusing on the view from a pharmacy perspective.\n\n\n\n	Register
	\n\n
DTSTART:20221122T143000Z
DTEND:20221122T170000Z
END:VEVENT
END:VCALENDAR