Comparative Analysis of Risk and Quality Management Tools for Accident Analysis and Learning-Addressing Inhaling Nitrogen Gas

Comparative Analysis of Risk and Quality Management Tools for Accident Analysis and Learning-Addressing Inhaling Nitrogen Gas

Risk- And Quality-Management Tools

Tool Name	Description	Applicability to Accident	Pros	Cons
Root Cause Analysis (RCA)	A systematic process for determining the underlying causes of an incident in order to prevent recurrence	This is useful for tracing the events that lead to the delivery and connection of the nitrogen tank.	·         A thorough examination of the incident’s underlying causes ·         Aids in the identification of systemic faults and areas for improvement	·         It takes time ·         Skilled facilitators are required ·         It may be limited to recognizing only the most evident and urgent reasons
Failure Mode and Effect Analysis (FMEA)	A technique for assessing and prioritizing potential failure mechanisms in a process	Applicable for evaluating potential failure modes in procedures involving the ordering, receiving, and connecting of gas cylinders.	·         Identification and prioritizing of possible failure mechanisms in a systematic manner ·         Being proactive allows for preventive measures	·         Based on assumptions and estimates ·         May fail to account for uncommon or unexpected failure modes ·         It may not provide information about human aspects
Healthcare Failure Mode and Effect Analysis (HFMEA)	An FMEA modification created primarily for healthcare processes.	Suitable for examining failures in healthcare processes, such as medicinal gas distribution in this example	·         Designed specifically for the healthcare business, addressing specific difficulties ·         Takes into account the impact on patients and healthcare professionals ·         Places a premium on ongoing improvement	·         A thorough understanding of healthcare processes is required ·         Outside of the healthcare industry, it may be less well-known or embraced.

How This Accident Could Have Been Prevented

Several actions may have been taken to prevent future mishaps like the one described in the study. To begin, improved communication and verification mechanisms should be implemented between the nursing home and the gas provider to ensure accurate deliveries, with unambiguous labeling on each gas cylinder. A robust routine for receiving and checking deliveries, involving multiple staff member verification, may have detected the problem before the nitrogen tank was attached to the oxygen delivery system. Furthermore, employee training on recognizing and managing various gas cylinders is critical to avoiding such deadly blunders. A robust quality management system that includes frequent audits and drills mimicking emergency scenarios would aid in identifying and correcting possible problems before they cause harm (Mökander et al., 2023). Finally, the establishment may want to think about implementing technology, such as barcode scanning or RFID devices, to automate and increase the accuracy of inventory management and delivery verification operations.

Prevention Method

The establishment of a complete Failure Mode and Effect Analysis (FMEA) procedure suited to the hospital context is the most appropriate prevention method for the accident in the report. FMEA systematically examines probable failure modes in a process, making it an effective tool for identifying and prioritizing risks associated with ordering, receiving, and connecting gas cylinders in a nursing home setting. An FMEA allows healthcare institutions to analyze each step of the process, including supplier interactions, delivery verification, and gas cylinder hookup protocols, in advance. FMEA identifies significant failure spots while stressing preventive and corrective steps to reduce the likelihood of future incidents (Anes et al., 2022). FMEA’s strength rests in its ability to give an organized approach to risk assessment, ensuring that potential failure modes are examined and addressed methodically. FMEA might have identified risks in the delivery and connection process in the context of the accident report, forcing the development of more vital communication protocols, stringent verification procedures, and focused employee training on handling different gas cylinders. FMEA develops a proactive safety culture that matches the complexity of healthcare operations, minimizing the likelihood of similar mishaps in the future by focusing on prevention rather than reaction.

References

Anes, V., Morgado, T., Abreu, A., Calado, J., & Reis, L. (2022). Updating the FMEA approach with mitigation assessment capabilities—A case study of aircraft maintenance repairs. Applied Sciences, 12(22), 11407. https://doi.org/10.3390/app122211407

Mökander, J., Schuett, J., Kirk, H. R., & Floridi, L. (2023). Auditing large language models: A three-layered approach. AI And Ethics. https://doi.org/10.1007/s43681-023-00289-2

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Read the accident report details for

“Accident: 837914 – Four Nursing Home Patients Died From Inhaling Nitrogen Gas” from the Occupational Safety and Health Administration (OSHA) to prepare for deliverable

Paper details: (https://www.osha.gov/ords/imis/accidentsearch.accident_detail?id=837914#)

create a table in which you:

Identify and compare at least 3 risk- and quality-management tools to address the accident detailed in the report. These tools would be used to analyze and learn from the accident.
Indicate how this accident could have been prevented or how to prevent similar accidents in the future.
Recommend and justify the prevention method you’d suggest as the best fit for the accident report in this assignment.

Audience
This table will be provided to your organization’s leadership team as a response to the OSHA report.

Cite any sources and format citations and references according to APA guidelines.