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1. Respond to with 140 words: Katherine- (Hello Team, Organizational processes
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1. Respond to with 140 words:
Organizational processes are put in place for facilities and organizations to be successful and decrease their potential of errors. Each entity that has these processes tries to ensure that their daily procedures are followed. However, the same routine of daily procedures could also cause oversight of detailed information such as the incident in the nursing home with the oxygen and nitrogen tanks. There are some workers who repeat their same daily routine and feel nothing changes. In return they don’t check every detail such as labels. A simple inventory process and safety training could have prevented these fatalities.
Although some errors are unintentional, such as an employee accidentally hooking up a tank with an incorrect label, there are also violations which are a deliberate deviation from the rules. Not reading the label before hooking up the tank was a violation of workplace procedure. Inadequate training and leadership can result in violations occurring. An unintentional error can happen when an employee is overworked or distracted. A violation can occur because some employees want to take shortcuts because of poor design or maintenance by the organization. Understanding these influences can help managers come up with strategies to constantly improve the Culture of Safety in the work place.
Sharp end individuals have direct contact with the patient when unsafe acts are committed. One common error made by a sharp end individual is the lack of proper diagnostic management. With proper diagnostic management, patients have a chance to prolong life if they are suffering from a chronic illness. The sharp end individual mistakenly connected a nitrogen tank to the oxygen delivery system in the scenario presented. The employee should have double-checked the labels on the tank which would have raised concerns when seeing a nitrogen label instead of an oxygen label.
Blunt end errors occurred when the individuals at the BOC either failed to properly label the tanks to begin with and by not confirming that it indeed was actual oxygen tanks that was delivered to the nursing home.
The five principles used the Culture of Safety Model are informed culture, reporting culture, just culture, learning culture and flexible culture. By informing the employees of the potential risks of not checking labels each and every time this tragedy could of been prevented. Reporting safety problems such as not seeing labels or incorrect label also would have helped manage the risk in this scenario. The just culture builds an atmosphere of trust in which employees provide safety related information (such as missing or incorrect labels) to management. Learning and flexible culture provides opportunity to learn from past mistakes so they do not happen again and the necessary changes are made to protect the patients and staff.)
2. Respond to with 140 words:
(Hello everyone ,
The conditions which played a role in this accident were negligence and not paying attention to detail from the nursing home and BOS Gases the supplier. Guidelines must be followed to keep patient safe and clearly the guidelines were overlooked and failed by BOS gases because they did not verify the tanks to make sure that all the tanks were oxygen. Unfortunately, the nursing home staff who had received the tank without verifying if it was set up properly was also negligent. The nursing home staff was carelessness and failure to follow the verification process led to the failure in which ultimately led to the patient’s safety and being compromise. The nursing home staff did not pay attention to detail and failed to follow proper procedure; which puts the patients and facility at risk or lead to a life threating incident like this one.
Sharp end staff in direct contact with patients did not verify or double check the delivery order of the oxygen tanks, there was no communication when the tanks were delivered to the nursing faculty to ensure all safety guidelines were followed.
Blunt end decisions made away from the bedside impacted the care; if the patient’s errors were made at the onset which BOS gases staff, the employees who took the order and the delivery person, both should have checked the order before it left the facility and rechecked it when it was delivered.
Risk can be managed by applying the 5 characteristics of a strong and safety culture, It is important to have open communication because it allows workers on all levels of the organization from entry level employees all the way and evaluate risks to reduce injury or death to patients to upper management, as healthcare provider, we must identify and evaluate risks to reduce injury or death to patients, visitors, and staff. All equipment should be inspected and verified before it is received for use, and there should always be refresher training to avoid such incidents.)