Quality Dimensions and Measures Table Paper

Quality Dimensions and Measures Table Paper

HCS/451

Quality Dimensions and Measures Table Paper

In December of 2000, Cincinnati OSHA office heard reports of two deaths at a nursing home in Ohio through media and police. The nursing home in question frequently ordered and received tanks containing pure oxygen. During one of the deliveries they were mistakenly given one tank of pure nitrogen by the supplier along with three tanks of pure oxygen. The nitrogen tank had both an oxygen and nitrogen label. A nursing home employee connected the nitrogen tank to the nursing home’s oxygen delivery system. This mistake caused two deaths and three additional residents to be admitted to the hospital in critical condition. Two of those three admitted to the hospital eventually died within the month. This paper will compare the Normal Accident Theory to the Culture of Safety model. It will also explain what factors can play a role in organizational accidents similar to the one highlighted in the scenario. On the other hand, the explain that why the FDA, not OSHA, was responsible for investigating this case and how the Culture of Safety model could have been applied to reduce risk in this scenario. It will also elaborate the five general principles used in the Culture of Safety model, and 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.

Factors Involved in Organizational Accidents

“Safety is expensive, but an accident is even more costly. All organizations, all business owners, all managers, supervisors, and workers in all workplaces need to understand the effect work performed on the human body and how we influence the demands of the work we do through human interaction,” (Bard, 2013). The main factor in this scenario above is the human factor. Most human factor errors occur from lack of communication or failure to properly read directions, which in the scenario neither was properly done because it was so routine to the employee.

Organizational processes are put into place for a reason and most companies enforce them in order to create a flow and ease the job for individuals. Often times professionals follow these policies and procedures placed by the organization and fail to realize that they are overseeing important issues. This oversight can be something simple or a potentially harmful mistake such as mistakenly using nitrogen instead of oxygen. In either event the mistake was more than likely an oversight. Unfortunately, this is something that occurs quite often and most employees are trained to just do their jobs instead of learning about certain risks and potential failures.

The sharp end individual is where most of these problems are found. These individuals enjoy working with issues and will do their best to prevent or fix any problem that may come their way. The errors and violations committed by sharp end individuals can lead to greater issues for an organization because these are the individuals trained to do the exact opposite.

Health care organizations and any professional that may be affiliated with them should continually work to improve patient safety and establish patient safety programs. These programs should provide clear and visible attention to safety through several outlets such as signs or lectures. Implementing systems that report and analyze errors can help to better understand what happens in unsafe conditions within the organization. Incorporating safety principles like standardizing and simplifying equipment, supplies, and processes can help to establish interdisciplinary training programs.

FDA, not OSHA, Responsible for Investigating This Case

In this particular case involving the deaths of four nursing home residents, the Occupational Safety and Health Administration (OSHA) determined that the Food and Drug Administration (FDA) should take the lead role in performing an investigation. According to the United States Department of Labor (2016), “With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance” (OSHA’s Mission). It is OSHA’s job to ensure employees are working in healthy, safe environments. Since this accident involved the death of nursing home residents due to an employee connecting a nitrogen tank to the nursing home’s oxygen delivery system, it was only appropriate that the FDA take a leading role in investigating this case.

According to U.S. Food and Drug Administration (2016), the FDA “is responsible for protecting the public health by assuring the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation” (What We Do). Because the incident involved a medical device (nitrogen tank) which caused the death of four residents, the FDA was the appropriate choice when choosing an investigator for this accident. The FDA is also responsible for reporting adverse events and other problems with medical devices and alerting health professionals and the public when needed to ensure the proper use of devices and the health and safety of patients.

Manage risk by applying each of the five principles

Manage risk is important in a healthcare care facility nurses that could be done by updated training concerning identifying the tanks. In healthcare, there may be situations where employees may become comfortable with a certain routine and this happens when an individual assumes that everything is the same all the time. It is equally vital to be aware at all times as with the incident in Cincinnati Ohio cost multiple individuals life. Lack of training had a major role in this unfortunate incident and improper communication between nurses and supplier. For example, when the nurses saw that the tanks had two labels that was a red flag and lack of communication with staff led to a wrong choice being made. If the nurse would have analyzed the situation she would have made a better choice asking a supervisor to get a second opinion. A safety model is designed for all employees to be acknowledged of the high-risk nature of an organization’s activities and the determination to achieve consistently safe operations.

A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment (PANet) 2016. The goal is to improve errors that are being made and at the same time provide the patient with the best care possible. Developing interpersonal relationships is important as well since it will determine if this will be a successful model within the healthcare operation.

Culture of safety and reduction in accidents

In the given scenario, one nitrogen gas cylinder was delivered in oxygen cylinders. Without any inspection, that cylinder was used instead of oxygen cylinder. However, if safety culture principles would be used, the residence lives could be saved. The poor management that did not foster take extra precaution while dealing with sensitive equipment results taking innocent lives. Another principle was effective team work that could check and monitor the supplies, highlight and detect (nitrogen gas cylinder). Nursing homes usually have senior citizens and population who is vulnerable to protect themselves from any danger; therefore, a great perception of employs to provide protection and healing environment for their residence could lead them to utilize extra precaution while providing any medical treatment.

Five principles of Culture of Safety model

Culture safety are collective measures and practices of norms and values in the health care organization that are utilized among employs to minimize the unavoidable incidents. There are five major principles that can contribute to promote the cultural safety. The patient safety starts from the upper leadership and go down all the way to the lowest level of management. The top management set the tone and work ethics for employs that foster safety for the patients and for employs as well. Communication that is based on trust and mutual respect is another principle that can promote and sustain safety culture. When employs have trust on management, they are more likely to share their concerns, questions and suggestion to management. Therefore, management take effected steps to solve any current or upcoming challenges with their employs support. Ineffective communication cannot only highlight flaws or drawbacks in the system but also hinder the solutions that come from workforce. Shared perception can increase the importance of Safety culture. Each organization has different approach and perception that suits the organizational vision and mission. Therefore, that different perception can increase the safety culture.

Health care facilities totally depend on different health professional who work in an integrates string to provide optimal results. Therefore, team work enable professionals to verify information, highlight any week area and provide maximum workforce to fix any current problem and issue. Organizations that have week teamwork tend to have more problems and major accidents than the organizations that have strong teamwork. Analyzing and studying prior incidents can enable the organization to gather data. This data highlights the mistakes, weakness of the system, management or employs that can be fixed to avoid future repetitive incidents (University of Phoenix, 2016).

Conclusion

In conclusion, this paper has compared the Normal Accident Theory to the Culture of Safety model. explained factors that contribute in organizational accidents similar to the one highlighted in the scenario. It also explains that why FDA, not OSHA, is responsible for investigating this case and how the Culture of Safety model could have been applied to reduce risk in this case. It also described the five general principles used in the Culture of Safety model, and 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.

Reference

Bard, L. (2013). Human Factors Influencing Workplace Safety. Retrieved from http://www.hazmatmag.com/features/human-factors-influencing-workplace-safety/

University of Phoenix. (2016). Weekly Overview, week three. Retrieved from University of

Phoenix, HCS451 website.

United States Department of Labor. (2016). About OSHA. Retrieved from https://www.osha.gov/about.html

U.S. Food and Drug Administration. (2016). About FDA. Retrieved from http://www.fda.gov/AboutFDA/WhatWeDo/