On Dec. 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.
Note: 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:
o How can 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.