A Short History of Recent Health Care Disasters and Lessons We Have Yet to Learn

This presentation will review and highlight a number of recent health care disasters in Canada and their aftermath. The purpose is to examine the lessons drawn from these misadventures, what policy and practice responses have ensued, and what still remains to be done. Were the disasters avoidable, and if so, at what cost? Did they arise by chance or because of system design? What have the patient safety and quality improvement movements taught us about performance and to what extent have we made their insights routine? Where do policy and incentives come into play? Is there a tension between clinical autonomy and system excellence?