The Institute of Medicine (IOM) developed six main goals of the healthcare system. These goals include safety, effectiveness, patient-centered attitude, timely reaction on different situations, efficiency, equity.
Safety assumes avoiding brining any kind of harm to patients during the provision of health care services. Medical personnel should make everything possible to avoid risks and dangerous actions in the course of treatment and other manipulations with their patients. It is needless to say that conscious brining of harm to patience is totally unacceptable practice. In addition, there are cases when doctors and nurses bring involuntary harm in the process of treatment. This can happen due to mistakes, uncareful attitude and other factors. These cases should also be avoided.
Effectiveness is another aim set up for the healthcare system. Scientific knowledge should be used to increase the effectiveness of treatment. Only knowledge does not guarantee positive results. It should be supplemented by the research results and practice. Effectiveness assumes not providing services, which do not bring benefits to patients. It is important to provide the most effective treatment, which gives the best results to patients. Doctors and nurses should avoid underuse and misuse in medical treatment. For example, in some cases the results of the treatment are better than were expected in the beginning. In this case, it will be important to stop medical manipulation in order not to give person extra medical help, which is unnecessary in this situation.
Patient-centered attitude should be the basis of the medical service. All aspects of the healthcare systems should be subdued to the idea of giving the most effective help to the patients. All process of treatment should be designed in order to give an adequate response to patients’ needs. Individual approach, high quality of medical service and respect to patients should be among the most important goals. It is necessary to take into account patients’ needs and desires, while taking decisions about treatment. For example, in the case of incurable diseases or difficult clinical cases the patients deserve the right to know the truth about their state, their future perspective and treatment methods, chosen for them. Human dignity should become the most important value for medical personnel and they should do everything possible to help patients save their dignity regardless of the complexity of medical case.
Timely medical help is another important goal, which should become one of the basic goals for the health care service. It is important to avoid delay for both, those who give medical services and those who perceive it. Delays may have fatal consequences when it comes to human health. Timely diagnostics and timely and effective treatment can make a great contribution to the process of successful recovery. The doctors everyday deal with different complicated medical cases, but they should not lose the speed of their reaction when dealing with different kinds of patients.
Efficiency is another important goal, which should direct the work of healthcare system. Efficiency should be achieved through the attempts to avoid any kind of waste, which includes the waste of time, equipment, energy and medical supplies. Different kinds of resources are limited and wasting resources medical personnel can leave other patients without necessary help.
Equity is another important goal of the health care system. All people who need medical help should be treated equally, regardless of their financial situation, social standing, racial belonging or religion. Human life makes the biggest value and there can be made no compromises in regard to this statement. All people who need medical help should have equal right to get this help.
Originally, the Normal Accident Theory was introduced by Charles Perrow after the accident at the Tree Mile Island nuclear power plant. The accident happened in 1979. After this accident Perrow expressed an idea that accidents are inevitable and thus should be treated as “normal”. The Normal Accident Theory is based on the ideas that accidents are inevitable. Pour (2007) describes four various factors, which can provoke accidents in the organization. These factors include: structure, strategy and culture. In the cases when accidents occur, the Normal Accident Theory puts responsibility on individuals. According to this theory individuals should care more about their safety. At the same time, there are cases which create additional risk for individual and create high probability of different accidents. Perrow defined interactive complexity and loose-tight coupling as two basic factors which determined system’s susceptibility to accidents. Interactive complexity describes unfamiliar or complex events or situations, which can become the reason of an accident (Perrow, 1999). There are organizations where risky and unpredictable situations occur oftener in comparison to other organizations. Tightly coupled systems are described as systems where parts of the process are tightly connected with each other and one part of the process has a strong influence on all other pats. In the tightly connected organizations failure in one of the organizational parts quickly has negative reaction to the performance of the entire organization. “According to the theory, systems with interactive complexity and tight coupling will experience accidents that cannot be foreseen or prevented. Perrow called these system accidents. When the system is interactively complex, independent failure events can interact in ways that cannot be predicted by the designers and operators of the system” (Tamuz & Harrison, 2006)). In the tightly coupled organizations the cascade effect can take place and result in multiple failures and accidents before the reason of the accident is defined. In these organizations even minor accidents can result in unpredictable and severe consequences. While describing two main factors, which contribute to the number of accidents in the organizations, Perrow comes to the conclusion that accidents and inevitable (Perrow, 1999). They can not be predicted and prevented. There is only a possibility to predict probability of risky situations, taking into account two factors mentioned above.
In the situation with Ohio accident and death of the nurses, at least one of the factors can be identified. Nursery home can be called a place of higher risk factor, due to big number of people who attend this place. This conditions create potential risks for the people who live there. At the same time, the type of accident, which took place in this place, could not have been predicted in accordance to the risk factors, peculiar for the nursing home. While evaluation potential dangers, the risk or misuse of the oxygen was not taken into account. The reason of accident was not taken into account because of low probability of such kind of accident. According to the Normal Accident Theory, such risks is normal and can take place any time and cannot be predicted and thus could not be prevented (Rochlin et al. 1987). This risk factor was not taken into account and there was no person responsible for the correct use of oxygen devices. “Perrow made an important contribution in identifying these two risk-increasing system characteristics. His conclusion, however, that accidents are inevitable in these systems and therefore systems for which accidents would have extremely serious consequences should not be built is overly pessimistic. The argument advanced is essentially that the efforts to improve safety in interactively complex, tightly coupled systems all involve increasing complexity and therefore only render accidents more likely” (Tamuz & Harrison, 2006). According to Perrow, only engineering solutions can be useful to increase safety. At the same time, in the accident described, it is evident that human error and lack of control on different stages of the process brought to fatal results. Perrow believes that redundant safety devices, as well as additional safety measures and human procedures are ineffective in preventing accidents (Perrow, 1999). At the same time, the situation described illustrates that some preventive measures and additional training, such as additional check ups, could have been effective in the prevention of the accident. The workers of the nursing home were not given proper instructions about potential dangers of the oxygen use. There were not developed necessary mechanisms aiming to control the proper use of oxygen. According to Perrow’s theory, this kind of accident could not have been prevented.
Perrow and other specialists, who count ton the Normal Accident Theory give multiple examples of different accidents, which could not be predicted or prevented by any means (Perrow, 1999). In each organization there are people, who are responsible for the safety measure within the organization. There people act in accordance with instruction and try to mind and prevent all possible accidents.
In the situation described, the Food and Drug Administration was the appropriate authority to investigate the case. This was reasonable, because medical issues became the reason of the accident. The FDA became concerned with the issue because the use of medical components became the reason of deaths.
The accident with the nitrogen poisoning in Ohio could have been prevented according to the Culture of Safety model. The culture of safety was not followed and this resulted in human victims. The person who installed cylinder did not pay proper attention to the name printed on the cylinder. Since there were two names, formally the person took a decision after reading the oxygen on the label. At the same time, he did not pay additional attention and did not estimate potential risks caused by the probability of making a mistake. The culture of safety was not formed within the organization. Each individual followed according to the instructions and did not put personal effort to increase the effectiveness and safety of the organization.
The type of thinking, which is formed in accordance with the Normal Accident Theory is different from the type of thinking, which is formed according to the Culture of Safety Model. In the culture of Safety Model each individual acts as a part of one larger unit and makes everything possible to prevent errors and accidents by any means. Not all possible accidents can be enumerated in the warning lists and instructions . That is the reason human factor become an extremely important in these situations. Individuals, who care about the safety of the process can become effective in preventing different accidents, which can not be predicted and calculated in advance (Carroll, 1998). In the case with Ohio nursing home, each member of the long chain could have noticed the mistake in the cylinders. The first person who put wrong cylinder with nitrogen was definitely guilty in making this mistake. This person takes major responsibility for the tragedy and human deaths. People who transported the oxygen cylinders and delivered them to the nursery room also did not notice the mistake. They followed the instruction and took cylinders from the place where oxygen cylinders were supposed to be stored. They did not take the time to check up if all cylinders contained oxygen. People who follow their instructions and do not care about safety of other people may miss different dangerous situations, because they do not take personal responsibility and are not ready to put effort to support general safety of the organization.
The culture of safety, when presented in the organization, influences all levels of the organization. Responsibility starts from the highest level, when the head of the organization knows that safety can be reached and does not treat accidents as thing which cannot be escaped (Marais et al., 2010). The next level of culture of safety is reached when such attitude is followed by all members of the organization. They follow the strategy of the head of the organization and take the idea that accidents can be avoided.
The main motivation comes from the inside. The employees should follow safety measures not because they want to escape punishment, but rather because the follow common goals and want to create safe surrounding for themselves and for their coworkers (Carroll, 1998). In this case, they become not afraid of personal responsibility and view it as their own benefit. In the Culture Safety Theory the accent is made on the process, not on the punishment.
Risk management centers on the events, which can take place in the organization. It does not pay much attention to human qualities of employees and center rather on the technical characteristics of the process. The Culture centers on the qualities of people. This approach is based on the idea that individual approach and human resources can help to prevent or correct any kind of emergency or accident. When people have deep and intrinsic link with the process they are involved in, they become ready to put their effort and their energy in the things they do (Rochlin et al. 1987). Such an approach can help prevent accidents and minimize risks associated with the working process. The cultural approach makes an accent on people, not in processes and mechanisms. It illustrates that people can meet any kind of challenges and give an adequate response to them. In the example with nitrogen cylinder, the accident could have been prevented, if any of the people, involved in the situation took more time to make the necessary checkup. This could be possible if the person was personally involved in the situation and were ready to invest time and effort in order to reach one common goal and to provide safety for all other members of the process.
Tamuz, M., Harrison M..(2006 Aug). Improving Patient Safety in Hospitals: Contributions of High-Reliability Theory and Normal Accident Theory, Health Serv Res; 41(4 Pt 2): 1654–1676.
Marais, K., Dulac, N., Leveson, N. (March 2010). Beyond Normal Accidents and High Reliability Organizations: The Need for an Alternative Approach to Safety in Complex Systems, Engineering Systems Division Symposium, MIT, Cambridge, MA.
Carroll, John S (1998). Organizational Learning Activities in High-Hazard Industries: The Logics Underlying Self-Analysis. Journal of Management Studies, 35(6), November pp. 699–717.
Perrow, Charles. (1999).Normal Accidents: Living with High-Risk Technologies. Princeton University Press.
Rochlin, Gene I., La Porte, Todd R., Roberts, Karlene H. (Autumn, 1987). The Self-Designing High Reliability Organization. Naval War College Review,.
Weick, Karl E., Roberts, Karlene H.(September 1993). Collective Mind in Organizations: Heedful Interrelating on Flight Decks. Administrative Science Quarterly, 38(3).