Analysis of Accidental Deaths in Healthcare
Human factors related to death of 73 year old man:
At first glance, it is very easy to attribute the switching of the man’s oxygen and suction tubes to human error by the nurse. However, it is also important to look at the factors that led up to that moment. Was she tired because of being overworked? Has she received the proper training? Was she aware of all the protocols that needed to be followed? Most of these can be attributed to organizational factors such as overstaffing or lack of proper education. The fact that this issue was, as far as we know, an isolated incident, human error appears to be the more likely candidate. If the error was related to organizational factors or systems complexity, there would likely be other occurrences.
Systems complexity factors related to death of 73 year old man: The systems complexity factors related to the death of the 73 year old man are not as apparent as the human and organizational factors. A possible systems error was the lack of differentiation between the oxygen and suction tubes. The hospital knew the importance of ensuring that nurses identify the tubes correctly because they required two nurses to check them. Knowing this, they could have implemented a system to better identify the tubes before the incident rather than after. Another systems factor is the process of reporting these incidents. Two of the violations Tucson Medical Center was cited for by CMS were “failure to promptly identify each of the five deaths” and “failing to notify the hospital’s board of the deaths.” These are both very serious issues. The death of the patient in July 2000, which was caused by their oxygen tank running dry during transport, could have prevented the death of the 73 year old man if it was properly reported and investigated. It likely would have led to a

Organizational