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 250-300-word paper in which your team compares the Normal Accident Theory to the Culture of Safety model. Include the following in your paper:

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.

Sample Solution

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Develop 2-4 pages Memorandum to evaluate the managerial issue and to answer the questions. Make sure to provide credible evidence supporting your recommendations and conclusions. Do not copy the case in the memo, but make sure to refer to its number for the faculty to have a reference for grading.
Mr. Parker is an 88-year-old resident of your LTC home with end-stage Alzheimer’s. He is wheelchair bound and spends most of his days sleeping in his wheelchair near a window facing the garden. He needs to be spoon fed but has recently started to refuse to eat. Mr. Parker has three children, one of whom is very involved in the care of her father. The team approaches the daughter about her father refusing to eat, and feels that his refusal is legitimate. Thus, they propose changing the plan of care to palliation. The daughter absolutely refuses, claiming that “you cannot kill my father, I want everything done to keep him living!”
What are some of the ethical issues in this case?
 Do we know whether the resident is capable to make his own health care decisions?
 Are there any known wishes from Mr. Parker? What would he want? What are his values?
 Is his daughter the substitute decision-maker? Can she, in this role, demand treatment and expect that you comply?

Sample Solution

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