1. Analyze what filters were in place to block effective communication between the hospital administrators, medical staff, and affected patients.
Given the information available in this scenario, I really only see one filter that really stands out that blocked effective communication. That filter is called role expectations and is defined in the reading as how people expect themselves, and others, to act on the basis of the roles they play, such as boss, customer, or subordinate. In the scenario, the role expectations that weren’t met were; the fluids that were placed in the empty should have been, at the very least, relabeled, furthermore in a hospital setting like this, the fluid should have been removed all together; the supervisors should have contacted the patients who came into contact with the fluid immediately.
2. Evaluate how the original problem could have been intercepted before it became a health care crisis.
In my time working for a big box hardware store, there were many OSHA approved processes involved where dangerous chemicals were concerned. I can only assume that a hospital has the strictest of procedures to follow where it could affect and/or harm so many people. The people who changed the hydraulic fluid should have had their own process for disposing of the old fluid and most definitely should have relabeled these barrels as hazardous.
3. Let’s assume that you have been hired to study the series of mix-ups that involved personnel employed by Automatic Elevator, Cardinal Health, and Duke Hospitals; propose your recommendation that would prevent a re-occurrence of this costly crisis.
I believe the best way to assure that this never happens again is a much more tedious system of checks and balances. When dealing with things that are hazardous to humans, it’s everyone’s business to see that it is being done properly. In this situation, each step from the changing of the fluid to the marking of the container it’s in, to its eventual disposal should have to be visually checked and then signed off on by at least 2 people.