Ambulatory or ancillary health care organizations




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

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:

  •  How organizational processes give rise to potential failures?
  •  How can certain conditions influence errors and violations within the

workplace? (e.g., operating room, pharmacy, intensive care unit)

  • The errors and violations committed by " sharp end" individuals.
  •  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


Format your paper according to APA guidelines.

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