Quality Dimensions and Measures

Quality Dimensions and Measures

Team D


Factors that play a role in organizational accidents

Often employees can get a bit overwhelmed when it comes to everyday processes. Even when it comes to the oxygen that is given for the patient’s health. The risk rises when the employees of the facility grow tired from long days of working. Other times the labeling on the products can lead to confusion. According to OSHA regulations, APPENDIX C TO §1910.1200—ALLOCATION OF LABEL ELEMENTS (MANDATORY)C.1 The label for each hazardous chemical shall include the product identifier used on the safety data sheet. There are two reasons that could have led to the incorrect tanks being used. One could have been, the tiredness of the member or it could have been the incorrect labels on the tanks.

Organizational processes that give a rise to potential failures

There are many circumstances that would allow a lot of confusion to happen. One being that the facility is not sanitary and have been properly built. This would be the foundation of the health care facility. Another factor to consider would be if the staff is working in a stressful environment. One of those stressful environments would be an operating room. When working under stress a person can get confused and have clouded judgement when it comes to using the proper tools to perform properly. This would be something that a human would expect. But professionally, it would be unacceptable to allow this to happen because you will have the life of another human in your hands.

Certain conditions that influence errors and violation

Based on the preliminary report provided by OSHA the deaths were as a result of incorrectly labeled and delivered oxygen tanks. The errors were plenty in this incident, from the oxygen supply company mislabeling the nitrogen tank as oxygen, the delivery driver giving the incorrectly labeled tank to the nursing home, and the nursing home for not inspecting the tanks and using them. The conditions were fatigue and laziness that lead to this avoidable loss of life. If the nursing home employees did their jobs and inspected the tanks before connecting to a large oxygen cascade system, the deaths may have not occurred. If the oxygen supply company employee followed the laws then to change a nitrogen tank to oxygen, you must drain the tank, clean the tank, hydrostatically test the tank, then repaint and relabel before you can refill thank tank with a new gas.

Errors and violations committed by “sharp end” individuals

Therefore, after all the evidence was gathered and looked at by the FDA (Food and Drug Administration) local law enforcement and the fire department who responded to the initial call for help. They found the oxygen label was placed over a nitrogen label. This is a violation of the health and safety code. As you can’t simply take a mark tank for nitrogen and change it to oxygen. The fire department captain could see two labels by looking at the tank. The nursing home staff failed to DICE (Drug/Dose Integrity/Indications Clarity/Contraindications Expiration date) the oxygen tank. This again is a clear violation as medical oxygen is a drug and regulated by the FDA and DEA. They also wondered if a lack of policies for receiving oxygen tanks at the facility and quality control at the oxygen supply company could have avoided these fatalities.

Breaching of defenses or safeguards

Unsafe acts in healthcare are like mosquitoes; one can try to thwack them one at a time, but there will always be other mosquitoes to take place of the killed ones. The only effective remedy for eliminating them is by draining the swamps and clearing the bushes where they breed. In the case scenario of the Cincinnati Occupational Safety and Health Administration that involved accidents at a nursing home in Ohio, ‘draining the swamps and clearing the bushes’ would be to promote the breaches of defense and safeguards that were broken that led to the death of four people and hospitalization of several other residents of the nursing home.

In fact, in the case scenario, there were several breaches of defense and safeguards that were violated, which led to the deaths and left others in critical conditions. The breaches of defense and safeguards started with one mistake, which was double labelling of one tank that contained nitrogen and led to other mistakes. Rather than seeking to confirm if the tank contained oxygen or nitrogen as the labels indicated, the nurse on duty went ahead and connected the nitrogen gas content into the nursing home. On the one hand, the medical supply should have checked the labeling before delivering the supply. On the other hand, the nursing home workers should countercheck the labels when receiving and before making use of the products. Basically, when breaches and safeguards are no longer in affect, it leads to accidents which should have been avoided (Carthey, 2013).

FDA’s responsibility for investigating the case

There is a distinct reason as to why the FDA, not OSHA, was responsible to investigate the case mentioned above. OSHA is designed to investigate all incidents in which workers are hurt in their working places. Basing my argument on this, then OSHA did not have the responsibility to investigate the case because it involved the nursing home residents or patients, not the employees and employer. The reason why FDA was suitable in investigating this case was because it has a responsibility to protect the American citizens from harmful foods and drugs. According to Miller and Palenik (2012), the FDA is mandated to regulate the manufacturing and labeling of medical devices with the intentions of ensuring not only the safety of the American populace, but also the effectiveness of the drugs and medical devices that they use. Therefore, the FDA was entitled to take lead in investigating the case to determine where the safety protocols failed, and who was ultimately responsible for the deaths and respiratory infections caused by nitrogen.

Culture of safety

Safety is the number one biggest concern among Healthcare organizations, which is why most instill a safety culture throughout their work environment. The biggest influence is finding solutions by highlighting problematic areas within the different departments. Having high expectations among staff followed with good communication, taking responsibility for your actions, showing good teamwork, and commitment to establishing a culture of safety are factors that will help keep any health facility safe (Barnsteiner, 2011).

According to the scenario the culture of safety could have been applied in order to reduce risk of accidently giving some patients nitrogen instead of oxygen. The culture of safety could have applied by staff members being more aware regarding what products were coming into the facility. Communication should have occurred from the vendor and the staff members as the employees at the nursing home shouldn’t always assume a vendor doesn’t make mistakes. If a staff member checked the items properly or informed the vendor to do so they could have noticed the mislabeling right away.

The five general principles

According to Barnsteiner (2011), “the essential elements of a culture of safety include, the establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency, and accountability” (Essential elements of a culture of safety). Safety should always be the number one priority which is why an organization should instill ways on preventing accidents or safety concerns from occurring. Most employers require training on safety and ways to report it, furthermore OSHA requires employers to hang up posters and educational flyers within the work place such as the break room. Teamwork is having everyone working together and being on the same page. Patient involvement is having patients become more active among their Healthcare as well as the facility that’s treating them for the care. Openness/transparency is being open to change and new methods to things that can be safer for patients or in the work environment. Lastly, accountability is taking responsibility for your actions. If you make a mistake you should tell your manager and work to improve it, so you don’t make that same mistake twice.

Actions that could have taken place

According to the culture of safety many actions could have been taken in order to have managed the risk more safely. As safety being a priority, all staff members should have taken safety precautions in order to make sure the tank was labeled correctly as well as going to the correct patient. Teamwork should have also taken place and in this case teamwork among the vendor and the employees. The team’s overall goal was to get those oxygen tanks delivered so the patients would have them when needed and making sure the items being delivered were correct. In this case patient involvement wouldn’t apply as it’s not their responsibility to check labels or hook up their own oxygen tank. Openness/transparency would have been having an employee unloading or checking in the tanks to ensure that no tank was broken/damaged or mislabeled. Lastly, accountability would have been all three parties involved (the warehouse that mixed up the tanks, the delivery driver/vendor that was responsible for the delivery that was leaving the warehouse, and the employees for not following a protocol on checking an item twice before giving to a patient. All in all, risk is bound to occur at any place but following the culture of safety can help to reduce that risk.


1910.1200 App C – Allocation of label elements (Mandatory). (n.d.). Retrieved from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1200AppC

New York Times. (2000). Oxygen nitrogen mix up is suspected in 3 deaths. Retrieved from https://www.nytimes.com/2000/12/09/us/oxygen-and-nitrogen-mix-up-is-suspected-in-three-deaths.html

OSHA Occupational safety and health administration. (2000). Inspection detail Report ID: 0522000. Retrieved from https://www.osha.gov/pls/imis/establishment.inspection_detail?id=18051615

Johnson, J. K., & Sollecito, W. A. (2013). McLaughlin and kaluzny’s continuous quality

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Miller, C. H., & Palenik, C. J. (2012). Infection control and management of hazardous materials

for the dental team. Brantford, Ont: W. Ross MacDonald School Resource Services Library.

Carthey J. (2013). Understanding safety in healthcare: the system evolution, erosion and

enhancement model. Journal of public health research2(3), e25.