One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system''s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable - does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada''s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture,
