Introducing the Case Medication mistakes also called advers

Introducing the Case

Medication mistakes — also called adverse drug events — are a major problem in US hospitals. The most common error is handwriting identification. Springfield General Hospital im plemented the Computerized Physician Order Entry (CPOE) system as a way to fix the problem. The result was an increase in adverse drug events.

1. What went wrong? How can you explain how the technology actually led to more rather than fewer mistakes?

2. What theories of change implementation would have helped the administrators at the Springfield General Hospital solve the problem of medication mistakes?

3. How might you have gone about solving the problem at Springfield General? To what extent, if any, would new technology have been helpful?

Solution

Adverse drug events refers to the problem arising due to confusion over drugs with similar names, effects of multiple drugs and patient allergies which the physicians are not aware of and other related errors.

What went wrong? How can you explain how the technology actually led to more rather than fewer mistakes?

Though the Springfield General Hospital implemented the Computerized Physician Order Entry (CPOE) system, there was an increase in the errors rather than any reduction. This is due to the below problems:

What theories of change implementation would have helped the administrators at the Springfield General Hospital solve the problem of medication mistakes?

The below theories can be used for effectively implementing the change in the Springfield General Hospital.

How might you have gone about solving the problem at Springfield General? To what extent, if any, would new technology have been helpful?

The below steps need to be taken to solve the problems at Springfield: