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Normal Accident and Culture of Safety
On December 7, 2000, the Cincinnati OSHA Office heard through media and police reports that there were two deaths at a nursing home in Ohio. OSHA determined that the FDA should take a lead role in performing an investigation.
Since the nursing home had many residents who had unhealthy respiratory systems, the nursing home routinely ordered and received tanks that contained pure oxygen. During one delivery, the supplier mistakenly delivered one tank of pure nitrogen in addition to the three tanks of pure oxygen that had been ordered. The nitrogen tank had both an oxygen and nitrogen label. An employee at the nursing home connected the nitrogen tank to the nursing home’s oxygen delivery system. This event caused two nursing home residents to die, and three additional nursing home residents were admitted to hospitals in critical condition. Within the following month, two of these three additional residents also died, bringing the total death toll to four.
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