The director of the Victoria Hospital Pharmacy has been forced by a request from his superior to confront and consider the possibility that people could die because of weaknesses in his operating systems. In a health care system, the operating environment must support, not only ideally, but in reality, 100% quality control with no defects. The one-time failure or lapse in the performance of the operating system(s) can have tragic consequences for all involved. The director must decide if Victoria Hospital Pharmacy is delivering the level of quality service expected of it by the public through its existing systems.
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