How would you clean prions off surgical devices? This isn't a case of workers not bothering to use soap, you know.
https://www.heraldnet.com/business/scientist-woodinville-com...
Not really. Persistent problems are management’s fault. Individual errors are made by individuals.
All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis.
You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.
Managers also exist inside a structure, one which they may not have created themselves, or where they lack power to make unilateral changes. Managers also often work inside highly competitive environments (e.g. capitalism) where much deviation from the current norm can be disastrous for both the organization and themselves.
At some point, any practical moral philosophy needs to direct some individual to change their actions. Morality without responsibility is powerless.
Ultimately it's the CEO's responsibility to lead a culture of safety. If the current norm is causing death and illness, it's their moral duty to push back against it.
Not every individual mistake can reasonably be averted with changes to the system, but it's vitally important that we at least ask the question of how the system failed. Otherwise we're virtually guaranteed to wind up with a pile of "unrelated incidents" that might have been prevented at little to no cost.
Management should have no reason to expect high standards at those prices.
But when someone is earning $8.50 an hour, and the manager overseeing them earns $100 an hour, I know who is responsible for the work.
The notion that people with low wages can’t be held accountable for errors EVER is... not reasonable
Well, who manages that guy? Even if literally everyone but the CEO barely earns a living wage, and you end up with results like those, I still know who is to blame.
Just go up the chain until you find someone who is paid enough to shoulder responsibility, even if it means you have to go all the way up to upper management.
Why are the devices so difficult to clean? Why are processes in sterile processing units so chaotic? Why aren't decontamination errors being picked up by quality control?
It's never the fault of the guy on $8.50 an hour. The buck stops with management; the buck always stops with management.