There’s no way to prevent all accidents from happening. However, an adverse event can have catastrophic consequences and certainly creates risk for the organization involved in the adverse event.This collaborative group discussion focuses on risk management using a real accident.Read the accident report, “Accident: 837914 – Four Nursing Home Patients Died From Inhaling Nitrogen Gas,” on the Occupational Safety and Health Administration (OSHA) website to prepare for your group discussion.Discuss the accident as a group and consider the following questions:What conditions likely played a role in this accident?How did those conditions influence errors and violations within the nursing home?What are the errors and violations committed by “sharp end” individuals and the “blunt end” individuals?What actions could have been taken to manage risk in this scenario by applying each of the 5 characteristics of a strong safety culture?

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