Virtual Conference – Just Culture and Incident Investigation

22nd November
14.00 – 17.30 (UK GMT)

Exploring the theme of patient harm arising from drug errors from different perspectives.
Jan Davies, Professor of anesthesiology and adjunct Professor of psychology at University of Calgary and Carmella Steinke Director of Safety Reporting for Alberta Health services in Canada (2 of the authors of the book “Fatal Solution”) will be discussing system safety approaches and how these can help in the development of a just culture.

To accompany this story we will be joined by Ken Catchpole, Professor of Human Factors at the Medical University of South Carolina who will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go.

We will be joined by Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds who will look at how you involve patients and families in serious incident investigations, together with a session run by Clare Crowley, National Investigator at HSIB providing a view from a pharmacy perspective.


14.00 – Welcome Sir Ian Kennedy – CHFG Patron

14.10 – Prof. Jan Davies, University of Calgary and Carmella Steinke, Alberta Health Services – Authors of Fatal Solution

14.50 –  Q & A on the Canadian case

15.20 –  Break

15.30 – Prof. Jane O’Hara, Health and Quality Safety, Leeds University

16.00 – Prof. Ken Catchpole, Prof. Human Factors, Medical University South Carolina

16.30 – Clare Crowley, National Investigator HSIB

17.00 – Q & A with speakers

17.30 – Closing remarks


Share this post on 
Social Media
Login to your account