Blog
Ambulatory Or Ancillary Health Care Organizations
QUESTION 1
Consider the following scenario:
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

