HOW CAN CERTAIN CONDITIONS INFLUENCE ERRORS AND VIOLATIONS WITHIN THE WORKPLACE?Since the nursing home had many residents who had unhealthy respiratory systems, the nursing home routinely ordered and received tanks that contained pure oxygen.
How can certain conditions influence errors and violations within the
Consider the following scenario:
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