How can certain conditions influence errors and violations within the?On December 7, 2000, the Cincinnati OSHA Office heard through media and police reports that

How can certain conditions influence errors and violations within the?On December 7, 2000, the Cincinnati OSHA Office heard through media and police reports that
there were two deaths at a nursing home in Ohio.

On December 7, 2000, the Cincinnati OSHA Office heard through media and police reports that
there were two deaths at a nursing home in Ohio. OSHA determined that the FDA should take a
lead role in performing an investigation.
Since 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 from 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:
o How 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 The errors and violations committed by “sharp end” individuals.
o How 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. 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. Cite at least 3 peer-reviewed, scholarly, or similar references and your textbook to support your
information.
Format your paper according to APA guidelines. QUESTION 2
Research inpatient and ambulatory or ancillary health care organizations.
Inpatient health care organizations:
Hospitals
Ambulatory or ancillary health care organizations:
Dialysis Clinic
Laser Eye Clinic
Pharmacy
As a team, select one inpatient health care organization and one ambulatory or ancillary health
care organization.
Create a 12- to 15-slide Microsoft® PowerPoint® presentation (the title and reference slides do
not count towards the total slide count) with detailed speaker notes in which you compare each
organization and their quality management performance as an organization.
Include the following in your presentation: Describe each of the health care organizations selected. Explain how to develop improvement capability for organizational performance.
o What resources are needed to develop improvement capability?
o Identify metrics used by each organization to measure each of the six
dimensions of high quality discussed in the Week Two Quality Dimensions and
Measures Table assignment.
o Describe similarities and differences between the metrics of each organization. o How do these metrics help develop improvement capability for each
organization?
o What quality improvement tools are available to help develop improvement
capability? Explain transformational improvement in relation to organizational performance.
o What transformational model(s) can be used to assist with transformational
improvement in relation to organizational performance? Cite at least 3 peer-reviewed, scholarly, or similar references and your textbook to support your
information.
Format your presentation according to APA guidelines.


 

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