Question

How do organizational processes give rise to potential failures. Please provide a reference.

Answer 1

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Processes in the organization can cause potential failure. According to High Reliability Organizing, "Negative synergy" in which the amount of errors in equipment, design and operator is much greater than the consequences of each person "(Perrow / Complex Organizations Usual Accident Theory). The mistake in each of those processes occurred in this case. The equipment obtained by the company was inaccurate. The person at the receiving dock would have checked every oxygen vessel after receiving the nitrogen to ensure that they received the correct number and the correct product. The FDA released a special warning about the gas mix-up, which claimed the lives of seven other patients in the same manner, so the company should have consulted its employees on the matter in order to pay particular attention to it. There was a malfunction of the machinery, so they didn't. In the next step, taking the oxygen to the floor and putting it by the bedside of the patient contained errors because the oxygen had not yet been checked or tested. Additionally, the operator who treated the oxygen / nitrogen should have doubled the drug to ensure that it was oxygen.

References:

Rao, A. S., & Camilleri, M. (2010). metoclopramide and tardive dyskinesia. Alimentary pharmacology & therapeutics, 31(1), 11-19.

Grandjean, P. (2015). Only one chance: how environmental pollution impairs brain development--and how to protect the brains of the next generation. Oxford University Press, USA.