Quality Dimensions And Measures Tables

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Quality Dimensions and Measures Tables
In 2000, a Cincinnati nursing home had an unfortunate accident in which a bottle of nitrogen was mistaken for pure oxygen. As a result, four residents passed away. This situation provides an opportunity for organizations to look at how their processes may lead to potential failures. It is also important to understand how certain conditions can influence errors and violation within the workplace. In this incidence, OSHA turned the case over to the FDA for further investigation. Health care administrators should understand the differences between the two agencies so that adverse events are reported to the correctly. Another vital role for a health care administrator is to understand the five principles of the Culture of Safety model, how the model could have been used to avoid this error, and how to apply them within their institutions to avoid other potential mistakes.
Perrow’s Factors and Higher Risks of Accidents Health care institutions are pitted against a barrage of potential hazards, some of which can be life threatening to the patient and employee. In the relentless attempt to secure and save lives, Charles Perrow suggests that complex systems are prone to inevitable accidents identifying three universal elements (Sollecito & Johnson, 2013, pp. 251-252):
1. Human error regardless of the level of skill and training will eventually falter.
2. Systems have natural flaws and multiple factors will trigger failure within the

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