Running head: CASE STUDY THREE 1
Case Study Three
Abigail Armstrong
Liberty University
Abstract
CASE STUDY THREE 2
This paper will analyze how the use of technology led to more problems rather than offering a
solution to reduce hospital errors. Springfield General Hospital implemented a new technology
without any prior analysis or background research. This analysis will explore specifically what
the issues of the technology were and what went wrong to lead to more problems instead of
fewer mistakes. Additionally, what theories of change implementation would have helped the
administrators of the hospital to solve the medication mistakes and ways the problem could have
been approached differently will also be covered. The main challenge for Springfield General
Hospital was incorrect dosage information, discontinuation failures, and patient confusion. This
paper will further explore the implementation plan that was followed and the steps the company
should have taken to make this implementation more seamless. The most important information
contained within this analysis will be how to integrate scripture into the action plan and how to
live according to the word of God when doing so.
Case Study Three
CASE STUDY THREE 3
Issues of Technology
The occurrence of medical errors is clearly not the ideal outcome for patients when
receiving care from a hospital, but these errors are also poorly reflected through a hospital’s
national scores and its reputation in the community. While technical advancement may seem like
a good solution to fix medical errors, the case that occured at Springfield General Hospital shows
how technical advancement can have a negative impact on a system if not implemented and
handled properly. The specific challenge Springfield General Hospital was trying to address was
prescribing errors and the effects it was having on patients due to medical allergies; the hospital
was attempting to make the problem better, but the changes contributed greater to the problem
and not the solution (Spector, 2016).
The specific problem with the technology was that the computerized physician order
entry (CPOE) system that was implemented was not designed with a proper plan to include a
pilot program (Spector, 2016). Some of the issues with the CPOE system included the following:
excessive amounts of clicks were required to access patient information, data coordination was
not successful between different areas within the chart, and there was missing information
displayed on the interface screen. The CPOE system was not designed to help provide care for
the complex scenarios that the hospital was dealing with. The correct safety measures were not
included in the design of the technology; for example, when an incorrect drug was entered, it
should have canceled or ordered a new drug in its place, but the system was not designed to
provide this level of detail or error proofing (McClellan, 2013). Additionally, the system
arranged patients according to their name and placed them in alphabetical order, but it should
have listed them based on their diagnosis or illness. The hospital staff needed to receive
extensive training on how to operate the new system and the limitations that would occur prior to
CASE STUDY THREE 4
the release of this new technology. The issues that Springfield General Hospital experienced
could have been handled more effectively without causing more harm than help to the patients
and the staff.
Change Implementation
Change implementation and change management are critical to the success of any
adjustment to a process or system. Planning for a successful change begins in the design phase
and continues through the implementation phase (Peng, Dey, & Lahiri, 2014). Prior to making
the major change to the system, the administrators at Springfield General Hospital should have
collected feedback from the employees of the hospital and analyzed any constraints within the
system. Communication is also a big success factor for any change that is being implemented;
when the staff are aware of a change that is coming, it gives them time to prepare and adjust
mentally so that the change can be made more effectively and efficiently (Peng et al., 2014). If
the hospital staff knew the limitations of the system prior to it being implemented, they would
have known to not rely on the system as heavily when prescribing medications and watching for
allergies. The frontline staff performs the duties each day, so they are the ones who can typically
provide a list of potential errors to occur prior to ever implementing a new system. It is important
to first speak with the people who will be responsible for using the system the most to
understand their feedback on what to watch for and how to implement the technology
successfully. From there, the frontline staff can also be used for continuous improvement
initiatives long after the initial implementation plan is complete (McClellan, 2013).
Personal Approach
CASE STUDY THREE 5
An alternate solution to the problem at Springfield General Hospital would have been to
first evaluate the controls and capabilities of both the system and the staff. A new system should
have never been implemented without these adequate measures taken first. According to Spector
(2016), change decisions ensure the organization has employees with the needed competencies
and behaviors; it also allows for the employees to become aware of the change and to know the
consequences of the change decision on the employees who will be impacted.
The new technology would have been helpful if the CPOE system would have correctly
rectified the medical history of patients, reported out on the stock availability of medications, and
provided a strategic way of organizing patient information. There are certain medications that
can only be taken for a certain amount of time, so the new system should have sent an alert to the
staff to notify them of this when the patient is taking one of these medications. Also, if there is a
shortage of medication, the staff should be notified that the patient will be given an alternative,
and the system should alert the staff of any issues or allergies that could be of concern with the
alternative medication. Proper training could have also made the new technology more
successful upon implementation; training directly impacts skills when there is a new technical
development in an organization, and sufficient training can make an entire implementation
process much easier for the employees to understand the system and be willing to adopt the
changes (Juris Bennett, Walston, & Al-Harbi, 2015). If the staff had been made aware ahead of
time of the limitations to the system, they could have been prepared for the potential
complications to come, and they would have been prepared for what difficulties and errors to
specifically watch for. Also, staff could know the benefits of the system and how to fully utilize
them to make their day-to-day work easier and more efficient.
Conclusion
CASE STUDY THREE 6
Springfield General Hospital implemented a new technology without taking the proper
steps for such a big change; the organization did not put in any effort to help the employees
prepare or adapt to the new technology and it made the problem much worse (Spector, 2016).
The staff was not resistant to the change, but they also did not entirely understand the new
system to be able to use it to their full advantage. If the staff had received some training prior to
the implementation of the new technology, many of the continuing issues could have been
avoided. Having open communication with the staff would have also allowed the intended results
to be more achievable; involving the staff in open dialogue about the changes to come with the
system could have prevented many of the mistakes and medical errors that were made in the
system after the implementation. Springfield General Hospital should have considered the
constraints of the system and the employees prior to ever adopting a change that could jeopardize
the safety of the patients they were caring for. Scripture states in 1 Corinthians 4:2, “Now it is
required for those that have been given a trust must prove faithful” (New International Version).
This verse shows how the hospital was not aligned with the word of God in this change. The
patients who are receiving care at this location have given their trust that they are being cared for
in the best way possible; however, with the way the new system was implemented, the
administrators were not entirely faithful in their roles by providing the best care. It can be argued
that the system allowed for medical negligence to take place, and the decision makers should go
back and reflect on this to make better decisions that align with the word of God moving
forward. They have a larger duty to serve others and not just themselves; they are making
decisions that provide medical treatment and care for large amounts of people who have put their
trust in them. Even as medical professionals, Christians have a duty to do what is best for others
according to the will of God and not what is best for themselves according to what their
CASE STUDY THREE 7
organization has defined as necessary. No matter how great a change the technology makes, if
the changes are not aligned with scripture, then they are not the right changes to make.
References
CASE STUDY THREE 8
Juris Bennett, C., Walston, S. L., & Al-Harbi, A. (2015). Understanding the effects of age, tenure,
skill, and gender on employee perceptions of healthcare information technology within a
middle eastern hospital. International Journal of Healthcare Management, 8(4), 272-280.
doi:10.1179/2047971915Y.0000000010
McClellan, J. G. (2014). Announcing change: Discourse, uncertainty, and organizational control.
Journal of Change Management, 14(2), 192-209. doi:10.1080/14697017.2013.844195
Peng, G., Dey, D., & Lahiri, A. (2014). Healthcare IT adoption: An analysis of knowledge
transfer in socioeconomic networks. Journal of Management Information Systems, 31(3),
7-34. doi:10.1080/07421222.2014.994672
Spector, B. (2016). Implementing organizational change: Theory into practice (3rd ed.).
Vancouver, B.C.: Langara College.
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