HCS/451 Quality Dimensions and Measures Paper

Assignment Content

As a team, consider the following scenario:

On Dec. 7, 2000, the Cincinnati Occupational Safety and Health Administration (OSHA) office heard through media and police reports that there were two deaths at a nursing home in Ohio. OSHA determined that the Food and Drug Administration (FDA) should take a lead role in performing an investigation.

Because 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 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.
  1. How do organizational processes give rise to potential failures?
  2. How can certain conditions influence errors and violations within the workplace (e.g. operating room, pharmacy, intensive care unit)?
  3. What are the errors and violations committed by “sharp-end” individuals?
  4. How does 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. (THIS IS MY PART #3)
  • 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 assignment.

Every reference used MUST have an in-text citation

Paraphrasing information is okay as long as it is properly cited in the text. If you have any questions about this please let me know ASAP

References need to be properly formatted according to APA standards. I have attached a link that has been super helpful for me regarding in-text citations and reference formatting.


Word count 200-250. I will edit as necessary to stay within max word count.

I have made a note on which small section is mine.

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