As a team, consider the following scenario:
On Dec. 7, 2000, the Cincinnati Occupational Safety and Health Administration (OSHA) office heard through media and police reports that there were two deaths at a nursing home in Ohio. OSHA determined that the Food and Drug Administration (FDA) should take a lead role in performing an investigation.
Because the nursing home had many residents who had unhealthy respiratory systems, the nursing home routinely ordered and received tanks that contained pure oxygen. During one delivery, the supplier mistakenly delivered one tank of pure nitrogen in addition to the three tanks of pure oxygen that had been ordered. The nitrogen tank had both an oxygen and nitrogen label. An employee at the nursing home connected the nitrogen tank to the nursing home’s oxygen delivery system. This event caused two nursing home residents to die, and three additional nursing home residents were admitted to hospitals in critical condition. Within the following month, two of these three additional residents also died, bringing the total death toll to four. (Based on accident #837914 www.osha.gov)
Write a 1,050- to 1,400-word paper in which your team compares the Normal Accident Theory to the Culture of Safety model. Include the following in your paper:
- Explain what factors can play a role in organizational accidents similar to the one highlighted in the scenario.
- How do organizational processes give rise to potential failures?
- How can certain conditions influence errors and violations within the workplace (e.g. operating room, pharmacy, intensive care unit)?
- What are the errors and violations committed by “sharp-end” individuals?
- How does the breaching of defenses or safeguards affect these accidents?
- Explain why the FDA, not OSHA, was responsible for investigating this case.
- Explain how the Culture of Safety model could have been applied to reduce risk in this scenario. (THIS IS MY PART #3)
- Explain the five general principles used in the Culture of Safety Model
- Explain actions that could have been taken to manage risk by applying each of the five general principles used in the Culture of Safety Model to this scenario.
Expert Solution Preview
The nursing home accident resulted in the death of four residents and three critical hospitalizations. The accident was caused by an employee who connected a nitrogen tank to the nursing home’s oxygen delivery system. This scenario provides an opportunity to compare the Normal Accident Theory and the Culture of Safety model. This paper aims to explain the factors that can play a role in organizational accidents and how the Culture of Safety model could have been applied to reduce the risk in this scenario.
1. What factors can play a role in organizational accidents similar to the one highlighted in the scenario?
Several factors can play a role in organizational accidents, including human factors, organizational factors, and external environment factors. In this scenario, human factors played a critical role in the accident as an employee mistakenly connected the nitrogen tank to the oxygen system. Organizational factors such as lack of clear labeling and inadequate training of employees on oxygen tanks’ handling and storage also contributed to the accident. The external environmental factor, which was the nursing home’s respiratory patients, increased the risk of the accident’s consequences.
2. How do organizational processes give rise to potential failures?
Organizational processes can give rise to potential failures through miscommunication, inadequate training of employees, inadequate supervision, faulty equipment, and poor safety culture. In the scenario, miscommunication was evident as the supplier mistakenly delivered a nitrogen tank labeled as an oxygen tank. The employees were not adequately trained on the handling and storage of oxygen tanks, leading to the employee’s mistake. Lack of supervision contributed to the accident as there was no one present to supervise the oxygen tank connection.
3. How can certain conditions influence errors and violations within the workplace (e.g., operating room, pharmacy, intensive care unit)?
Certain conditions can influence errors and violations in the workplace, leading to accidents. In the operating room, pharmacy and intensive care units, several factors such as inadequate staffing, equipment failure, inadequate training, and fatigue can lead to errors and violations. Fatigue, for instance, can cause errors in judgment and reaction time, leading to accidents. Inadequate staffing can lead to overworked employees resulting in errors and violations.
4. What are the errors and violations committed by “sharp-end” individuals?
Sharp-end individuals are those who are directly involved in performing tasks. Errors and violations committed by sharp-end individuals include poor communication, inadequate training, inadequate supervision, and lack of knowledge or experience. In the scenario, the sharp-end individual was the employee who connected the nitrogen tank to the oxygen delivery system, leading to the accident.
5. How does the breaching of defenses or safeguards affect these accidents?
The breaching of defenses or safeguards exposes an organization to potential accidents. Accidents occur when an individual or a system fails, leading to a breach in defenses or safeguards. The result is an increased risk of accidents and harm to an organization’s members or the public. In the scenario, the lack of clear labeling and inadequate employee training on handling and storage of oxygen tanks led to the breaching of defenses or safeguards, resulting in the accident.
6. Explain why the FDA, not OSHA, was responsible for investigating this case.
The FDA, not OSHA, was responsible for investigating this case because the incident involved the medical equipment used, the oxygen tanks, which are regulated by the FDA. The FDA has the mandate to investigate incidents or accidents involving medical equipment, while OSHA investigates accidents related to occupational safety and health.
7. Explain how the Culture of Safety model could have been applied to reduce risk in this scenario.
The Culture of Safety model is an approach to improving patient safety by promoting a culture that supports a system approach to error prevention. The Culture of Safety model could have been applied to reduce the risk in this scenario by implementing the following steps:
1. Leadership commitment to safety: The nursing home leadership should have shown a commitment to safety by promoting safety as a core value, encouraging open communication on safety issues, and supporting the development of a robust safety culture.
2. Patient safety management: The nursing home should have established a patient safety management program that identifies potential risks and implements corrective actions to prevent them.
3. Employee involvement: The nursing home should have encouraged employee involvement in safety initiatives by empowering them to report safety issues and participate in safety programs.
4. Continuous improvement: The nursing home should have promoted continuous improvement in patient safety by evaluating safety programs’ effectiveness and implementing changes to improve their effectiveness.
5. Learning and education: The nursing home should have provided regular training and education to employees on safety procedures, proper handling, and storage of medical equipment, and communication to prevent accidents.
This scenario highlights the importance of a culture of safety in preventing accidents in healthcare organizations. Human factors, organizational factors, and external environment factors can play a role in causing accidents. Applying the Culture of Safety model can reduce risk in healthcare organizations by promoting patient safety management, leadership commitment to safety, employee involvement, continuous improvement, and learning and education.