Employees also failed to take standard precautions, failed to make constant contact with patients during procedures. Human errors in the overdose of patients were evident. When dealing with human life, technicians were clearly careless, non-attentive in some cases, and showed a lack of appreciation for the risk involved in the operation of the machinery. Other factors were poor training of technicians as well as a lack of sufficient penalty to the technicians involved. Attorneys for the family against the machine manufacturer (AECL) The Therac-25 design eliminated many of the hardware safety features that been built into previous designs, assuming the software was functioning correctly and eliminated the need for safety features.
Patient lost 14 lb. in one week. b) Safety problems: Compromised safety awareness, evidenced by reported weakness and confusion. Supported by statements of “my mind just feels so cloudy” and failing to remove or fix the rug; patient’s poor safety awareness could be aggravated further by patient’s non-compliance with oxygen supplementation orders and noncompliance with physician’s orders, as evidenced by denial of the need to use oxygen when findings at hospital were determined to be necessary. c) Self-esteem problems: Ineffective coping is a lack of ability or desire to response appropriately or according to every day challenges (Myers et al., 2002 P 47) as evidenced by statement of “I just don’t work a lick”, “since Woody died.
They stated that: * There was a systematic failure to protect people in their care. * Castlebeck had failed it’s legal duty to notify the CQC of serious incidents including injuries and patients going missing. * Staff didn’t appear to understand the needs of the people in their care and some staff were too ready to use restraint without considering alternatives. * Background checks on staff weren’t carried out * Planning and delivery of care did not meet individual needs * They didn’t have good enough systems in place to assess and monitor the quality of services * They did not identify, and manage, risks relating to the health, welfare and safety of patients. * They had ignored their own complaints procedures * Staff investigations were not robust * They didn’t have agreements in place to protect people against unlawful or excessive use of restraints.
She said " The instructions were not clear or consistent or specific enough. The care staff really weren't being directed adequately." She added that some changes had been made after the CQC inspection but there was still "confusion" over the information in the written care plans. Coroner Keith Wiseman said " This was a death that should not have taken place in
Ordering was not consistent and the pattern of this procedure was that the trust were making their order either the start of the financial year when budget became available or at the end of the financial year when budget were being cleared out so it seemed that there was demand only two months of the year. Supplier were finding difficult to keep up and adjust capacity to meet the demand peaks even though they took on extra staff during this peak. This uncertainty due to the lack of coordination between the Suppliers and NHS caused problems for the hospital as they would frequently unable to receive goods and services when they were required. There was no
The contract was not vetted through all the departments and the specifications were approved by only one department head, the IT Director. C. Sam Sliderule, Inventory and Spares Manager, is thoroughly unsatisfied with the initial tests of the system – calling them a “disaster” - and the system is 4 months behind schedule. Additionally, the regional and centralized inventory management system is 10 months late. D. Jana Perry, director of Information Technology, has also used the system and thinks it works well, however she has a M.S. in Information Technology which implies the system does function however it is not user friendly.
For example, there were no longer any engineers left who knew how to build or maintain aqueducts. This meant that when these structures broke they couldn’t be fixed, and so over time there was less provision for clean water. The local population used the stone from the bath houses and other structures to build their own homes as there was less emphasis on public health. The new rulers of Britain did not think it was as important as the Romans had. By 1350 there were some quite serious public health problems in towns, where the lack of fresh water and drainage was a problem which caused the water to be contaminated by other sources and was not healthy to drink.
IRIDIUM CASE STUDY We believe Iridium has one major flaw in the marketing of their global satellite phone system. Iridium did not create a strategic marketing plan at the beginning of the product development process. Iridium started with a perceived problem by management and then developed a solution. When Iridium first started the development of their satellite system, the problem may have been a valid. But the solution took years to develop and the market was never resampled or reevaluated.
They didn’t show me how to use the washer so I had to ask someone to help me work it. No body told me that it was going to overflow and when it happen to me I didn’t know what to do. The whole floor was full with water and everyone got mad at me. The manager just assumes that I can do everything with out any training. The absent of the boss also became a problem.
It was clear that the strategic vision, Carly Fiorina had been using to guide the company, digital, virtual, mobile, personal, was not being executed. The company was unclear, and nobody in the company had any idea if the vision was being carried-out or not, and if it was, was it being carried out properly. Without a well-defined strategic vision for the company, employees had no sense of organizational purpose and no motivation. As a result of the lack of understanding of the vision, it resulted in a number of symptoms such as poor image, slow growth and a decline in sales, which is a direct connection to imprecise strategic vision and lack of leadership. The second of the HP’s problems was its confusing matrix structure.