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Running head: CASE STUDY #3
Case Study #3 –
Making the Problem Worse: Springfield General Hospital
Dusti Goertz
Liberty University
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Running head: CASE STUDY #3
Abstract
This paper will explore what actually happened at Springfield General Hospital. It will
answer the question of why the technology, which was supposed to help the staff, resulted in
confusion. Further, this composition will also contemplate which specific changes should have
been made in order to help the users of the new tech to adequately understand how to utilize the
new system. Finally, this paper will make suggestions as to what Springfield General Hospital
should do, both now and in the future, in order for their employees to avoid errors when using
the hospital’s technology.
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Running head: CASE STUDY #3
Introduction
Springfield General Hospital, an inner-city teaching hospital, along with many if not all
other hospitals, have been dealing with patient errors for an untold amount of years. While there
were various problems in other hospitals, the most common problems at Springfield General
Hospital were that of the poor/unreadable quality of doctor’s handwriting, overall patient name
mix-ups, drug prescribing errors, the effects of prescribing multiple drugs concurrently, and
being unknowing or inattentive to patient allergies (Spector, 2013). That being the case,
Springfield General turned to technology in order to decrease errors, and increase patient safety.
Being that it was widely believed that the use of technology is the ‘key’ to improvement in
accuracy, and in an attempt to reduce the amount of potentially lethal errors which were plaguing
the hospital; they followed this seemingly sound advice. Although the goal was improvement,
that was definitely not the result at Springfield General Hospital.
What Went Wrong
While there were a number of things which went wrong at Springfield General Hospital,
there was one main problem. That being said, it was not a problem with the tech which caused
the increase in problems. Yes, the patient issues may have escalated, but it was not due to any
fault of the system. The actual difficulty was that there was a complete lack of strategic planning
prior to the launch of the new technology which was to control patient files. This specifically
manifested itself in the overall lack of understanding on how to accurately utilize their newly
installed software system. While this specific difficulty arose in what would be called the
refreezing stage of Lewin’s change model, the issue’s roots actually stretch back into the moving
phase of the model. According to Spector, the moving phase of Lewin’s change model is defined
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Running head: CASE STUDY #3
as being, “the second stage in Lewin’s change model in which group members alter their patterns
of behavior” (Spector, 2013, p. 29). It was during this period, when the employee’s new work
behaviors should have been ‘cemented’ in place, instead of leaving questions as to the correct
means of using the new equipment.
What Could Have Been Done Differently
While there are always a multitude of things which could be done differently when
changes are made in an organization, there was one clear need at Springfield General Hospital.
That need was for training in both the correct way to use the new technology. This, once again,
references back to Lewin’s change theory. The hospital has the first stage, that of unfreezing,
under control. They knew what the problems were, and there was dissatisfaction regarding the
instances of ‘inaccuracies’ in patient care. The case study states this when it references the
“prescribing errors, confusion over drugs with similar names, inadequate attention to the
synergistic effects of multiple drugs and patient allergies” which took place in the hospital before
the integration of the system (Spector, 2013 p. 148). The portion of the change theory where
everything went ‘sideways’ is that of the moving stage. During this stage, all of the staff who
would be utilizing any part of this new system should have been thoroughly trained in its usage
(Bartunek & Woodman, 2015). Had that been the case, then the workers would have known that
the dosage information relied on what the pharmacy had order or in-stock, instead of the
recommended dose for an ailment. Further, the staff could have potentially had fewer instances
of interrupted treatments had they understood that prescribing or changing medications was a
separate process from the complete cancellation of a given medicinal therapy. If these, and all of
the other ‘quirks’ of the CPOE system would have been understood, perhaps the staff could have
decreased the number of patient related errors instead on multiplying them. Finally, since the
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Running head: CASE STUDY #3
moving stage was so botched via the lack of strategic planning/training, the refreezing stage was
bound for failure. Being that no one really ‘knew’ how to utilize the system to its fullest ability, it
became more of a hindrance, or a threat, than a benefit.
How to Fix This Issue
Even though it would seem that the integration of the new software at Springfield
General Hospital was a total waste; that does not have to be the case. The hospital’s ‘best bet’
would be to re-train everyone who interacts with this technology regarding the correct usage of
this system. This could be viewed either as moving backwards through Lewin’s change model,
from refreezing to moving, or as a whole new ‘change’ (van den Heuvel, Demerouti, Bakker, & Schaufeli,2013). Th
atmosphere of discontent regarding the actual functionality of the CPOE system may be best
suited if used as a ‘re-do’ of their earlier integration attempt. While they may face some
opposition from those who had encountered the inaccuracies and/or errors in the system during
use, the firm should give this tech option a ‘fair shot’, with people who actually know and
understand how to use it, before they move on to other options as a last resort.
Biblical Integration
The main concept within this case study revolves around mistakes, and how to recover
from them. Springfield General Hospital has a very good opportunity to recover from this
kerfuffle if they handle their situation correctly. We, as Christians, know that all we need to do is
to turn to our God in order to gain both wisdom and support for the next time we are faced with
difficult situations. The concept of turning to God in times of need is addressed very thoroughly
in the Bible. One instance can be seen in Proverbs 24:16 (Standard English Version) which
states, “For the righteous falls seven times and rises again, but the wicked stumble in times of
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calamity”. Another scripture reference for this guidance is Romans 8:28 (Standard English
Version) which reminds us “And we know that for those who love God all things work together
for good, for those who are called according to his purpose.” Finally, Psalm 145:14 (Standard
English Version) very succinctly states that “The LORD upholds all who are falling and raises up
all who are bowed down”. As our Father, God wants us to be successful in our lives. In times of
failure we need look no farther for guidance and consolation than His loving words.
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References
Bartunek, J. M., & Woodman, R. W. (2015). Beyond Lewin: toward a temporal approximation
of organization development and change.
Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., &
Owens, M. G. (2014). Facilitating Lewin's change model with collaborative evaluation in
promoting evidence based practices of health professionals. Evaluation and program
planning, 47, 82-90.
Spector, B. (2013). Implementing organizational change (3rd ed.). Upper Saddle, NJ: Pearson.
van den Heuvel, M., Demerouti, E., Bakker, A. B., & Schaufeli, W. B. (2013). Adapting to
change: The value of change information and meaning-making. Journal of Vocational
Behavior, 83(1), 11-21.
