Case Study 3: Making the Problem Worse
This case study explains what went wrong at Springfield General Hospital and how technology actually led to more rather than fewer mistakes. This case study will also explore theories of change implementation that would have helped administrators at Springfield General solve the medication mistakes sooner rather than later. Lastly, how the hospital can solve the problem, and to what extent, if any, would new technology have been helpful.
Keywords: change implementation, computerized physician order entry (CPOE), medication errors, adverse drug events, mutual engagement, shared diagnosis
According to Cohn (2015), “most of us think of hospitals as places of healing, and usually they are. But hospitals are also places where people get sick or are injured, thanks to medical errors” (p. 1). During Thanksgiving 2010, an article was generated about the poor efforts to reduce hospital errors. A study by Grady (2010) found “that harm to patients was common and that the number of incidents did not decrease over time” (p. A1). Therefore, over the years hospitals have looked for ways to avoid mistakes, however, some have made matters worse.
What Went Wrong
Springfield General Hospital was determined to use technology to correct hospital errors within their organization. The chief administrator made the decision that technology could help prevent medication mistakes in particular. Spector (2013) stated:
“Prescribing errors, confusion over drugs with similar names, inadequate attention to the synergistic effects of multiple drugs and patient allergies—those and other related errors that are lumped together under the label “adverse drug event” –kill or harm more than 770,00 patients annually in U.S. hospitals” (p. 147).
Because of this health care cost rose several hundred billion dollars due to adverse drug events. Ironically, the most common type of medication error is poor or illegible handwriting by the physician prescribing the drugs.
In order to rectify these issues, Springfield General sought a computerized physician order entry (CPOE) method to solve medication errors. The Journal of the American Medical Informatics Association Processing (2013) found that “a prescription drug order through a CPOE system decreases the likelihood of error on that order by 48% (95% CI 41% to 55%)” (p. 470).
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The hospital was supposed to adapt to four new standards provided by the CPOE. First off all medications and treatment had to be entered in the hospital’s system. Secondly, the entries were made available to all staff as well as pharmacy staff. Third, due to the design, the system would catch all prescription errors, such as “incorrect dosages, duplicate requisitions, patient allergies, and even adverse affect impact statements of multiple medications being prescribed to a patient” (Spector, 2015, p. 148). Fourth, the medical history of all patients would be displayed along with their current clinical guidelines for treatment. All of these steps assured Springfield General that this system would solve all of their existing medication error problems, instead, they received some disappointing information.
In actuality, the CPOE system that Springfield adopted actually increased adverse drug events and did not eliminate errors. There were multiple dosage errors due to the pharmacy not being aligned with the clinical guidelines. Therefore, some of the dosages that they may have been prescribed were not available in the pharmacy which caused the system to choose the dosage that was available. The system design did not take into account medications being discontinued or drugs with similar names. Synergistic effects of multiple drugs and patient allergies were inadequate. The display accessibility was limited when patients had a long history of medications resulting in multiple screens being displayed. Also, patient records font was displaying small and hard to read at times. As well as, the patient’s name did not appear on every screen that was associated with them. Therefore, this caused confusion among physicians when trying to assign medications and switch among screens.
Theories of Change Implementation
Mutual engagement and shared diagnosis should have been considered during the change implementation. Erickson (2016) noted, “that communication and patience is key, and both community and hospital pharmacists need to be involved with the CPOE development process to improve medication safety” (p.1). From beginning to end the hospital staff and pharmacy need effective communication between one another. By partaking in an IT project from the beginning, pharmacy staffs would be able to guarantee that their expertise helps guide the process in a way that aligns with their organization’s goals. If departments were sharing their opinions and diagnosis of the system then the view and accessibility issues would have been caught early in the testing stages as well. System administrators could have made the required adjustments.
Solving the Problem
CPOE systems have unquestionably prevented errors, however, they have inadvertently caused errors as well. The key is to continue developing ways to minimize the errors unintentionally caused by the system. “For example, when designing systems, more care should be taken to address common problems such as brand versus generic drug names, ineffective searching in terms of filtering drug names and regimens, and confusing screen displays”, Erickson (2016) states (p. 1). Another area that needs improvement is the flow of accurate and updated information from the hospital to the pharmacy.
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Springfield General’s communication with hospital pharmacists is needed in order to improve medication errors. Pharmacists should be providing drug counseling with patients as a safety check to make sure patients are taking the correct drug and dosage. Also, another system may be needed to perform automatic checks. Kaushal and Bates declared, “CDSSs offer additional functions for the provider to use, such as drug interaction checks, drug allergy checks, and prompts for the provider about when to order a service for a patient” (p. 4).
To improve entering information in for the wrong patients, system administrators could set up a link to verify patients before any data is entered in their record and when prescribing medication. If the link isn’t feasible staff should be forced to enter in specific information about the patient in order to access their records. In regards to accessibility, there are many things that the hospital and system admins of the CPOE system could implement to resolve that issue. A side-by-side view may be better than having screens aligned behind one another. Also, the system should allow users to customize the font and sizing according to their preference.
In conclusion, CPOE systems have great potential to be an effective solution for hospitals. They eliminate illegible handwriting, integrates electronic medical records and enables faster data and order transmission to pharmacies as well as other areas in the hospital. By integrating with other systems, such as decision support systems, it increases patient safety and improves the quality of patient care. If designed and implemented correctly, CPOE systems could reduce medical errors and ADEs experienced in the US. Organizations that adopt this method have to make sure that they are trained properly, the user interface is not poorly designed, verification of usability is performed during design, implementation, maintenance, and modification.
Apostle Paul states; “Do you not know that those who run in a race all run, but only one receives the prize? Run in such a way that you may win” (Corinthians 9:24 New International Version). In order for Springfield General to gain and succeed, everyone within the organization must change and adhere to the changes. The whole hospital has to run in a way that everyone wins, just as Apostle Paul stated above. Mutual engagement and shared diagnosis have to be active and prevalent in order for the hospital to effectively implement and use the CPOE system. Advancements and improvement require all hands on deck to reach the desired goal. An organization can not win if they aren’t running together.
- Cohn, J. (2015). A picture of progress on hospital errors. The Milbank Quarterly, 93(1), 36-39. doi:10.1111/1468-0009.12104
- Erickson, A. (2016). Connecting the CPOE dots: Where do we go from here?. Retrieved from https://pharmacist.com/article/connecting-cpoe-dots-where-do-we-go-here
- Grady, D. (2010). “Hospitals Make No Headway in Curbing Errors, Study Says.” New York Times. A. 1. SIRS Issues Researcher.
- Howlett, M. (2018). 2 the impact of health information technology on medication errors in a pediatric intensive care unit. Archives of Disease in Childhood, 103(2), e2.12-e2. doi:10.1136/archdischild-2017-314585.2
- Kaushal R., Bates D. W. Computerized Physician Order Entry (CPOE) with Clinical Decision Support Systems (CDSS) Agency for Healthcare Research and Quality; 2013. Available athttp://psnet.ahrq.gov/primer.aspx?primerID=6 (accessed January 27, 2014).
- Quinn, R. (2012). Report: Wrong-Patient Orders Occur Frequently with CPOE Systems. Retrieved from https://www.the-hospitalist.org/hospitalist/article/125175/patient-safety/report-wrong-patient-orders-occur-frequently-cpoe-systems
- Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association: JAMIA, 20(3), 470-6.
- Spector, B. (2013). Implementing organizational change: Theory into practice. 3rd ed. Upper Saddle River, NJ: Prentice Hall.
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