Quality Management

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
Iperfonning an investigation. I
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.

Explain what factors can play a role in organizational accidents similar to the one
highlighted in the scenario.
o How do organizational processes give rise to potential failures?
o How can certain conditions influence errors and violations within the workplace
(e.g., operating room, pharmacy, intensive care unit)?
o What are the errors and violations committed by “sharp end” individuals?
o How does the breaching of defenses or safeguards affect these accidents?



Sample Solution

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