RUNNING HEAD: CASE STUDY 3
Case Study Three
Jafari Harris
Liberty University
Author Note
Jafari Harris
Liberty University The author has no known conflict of interest to disclose.
Correspondence concerning this submission should be addressed to Jafari Harris, 14406 Silvertip
Ct, Jacksonville FL 32258. Email: joharris@liberty.edu
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CASE STUDY 1
Abstract
This paper’s main focus will be to showcase how the use of technology did not help to correct an
ongoing problem at Springfield General Hospital but instead made the situation worse. The
administrator at Springfield General Hospital, which is an urban teaching hospital, was
determined to solve its medication error problem by exploring the use of technology. With the
implementation of a technology system called Computerized Physician Order Entry (CPOE),
Springfield General Hospital, aim was to cut down on the prescribing medication errors as well
as solve the confusion of drugs with the similar names. Springfield General Hospital had very
high expectation of the CPOE technology, but computerized physician order entry failed to also
resolve an issue of reading doctors’ handwriting. Though adding CPOE to Springfield General
day-to-day operation was supposed to make things better, it did the opposite due to poor data
entry.
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CASE STUDY 1
WHAT WENT WRONG?
This paper illustrates the how Springfield General Hospital introduced a new
computerized technology system called Computerized Physician Order Entry (CPOE), to combat
an ongoing error that hospital was currently facing. COPE was brought on by Springfield
General Hospital administrator to not only resolve several errors, but also to cut down on cost.
CPOE intent was to also reduce medication errors, stop duplicates requisitions and provide
patient’s complete medical history which was tied to the latest clinical guideline for treatment.
(Spector, 2019) Rather than Springfield General Hospital being able to correct these ongoing
issues as expected with CPOE technology, they were met with shear disappointment because
CPOE did not deliver on the promise of eliminating the errors. According to Spector (2019)
CPOE technology not only failed at resolving prescribing errors; it also created confusion over
drugs with similar names which killed or harm more than 770,000 annually with adverse drug
event. (p. 147) In several situation, CPOE system increased adverse drug and provide incorrect
dosage information to house staff, that led to mix-up in patients receiving the wrong dosages.
According to an online study, Björkstén et al. (2016) they were a total of 613 medication errors
made and the most common were due to wrong dose in additions to, wrong patient name and
omission of drug, along with the lack of adequate access to guidelines that were found in several
cases as well. (p. 431) Medication errors can also be contributed to poor patient inadequate
ability to understand the medication that they are being prescribed by their physicians. Even
though this study may be alarming to most, it is not uncommon for patients to lack adequate
information for proper medicine usages.
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CASE STUDY 1
IMPLEMENTING THEORIES OF CHANGE AT SPRINGFIELD GENERAL
HOSPITAL
The implementation theories of change that would have help Springfield General
Hospital, would have been for the hospital to take a close look at the medication as it was being
distributed to its patients for accuracy. This accuracy check would involve verifying the patient
name and the prescribed medication being given against physician orders, as well as notifying
the medical doctor for clarification should there be any doubt. According to Spalla & Castilho,
(2016) the majority of medication errors were due to not only medication omission, but also due
to pharmaceutical interventions. As a result, pharmacists-based reconciliation can have a relevant
role in preventing medication errors and adverse events. (p. 143) Computerized physician order
entry technology was selected by Springfield General administrator, because of its accuracy to
reduce human errors by way of entering all hospital’s data into CPOE information technology
network. “The computer entries would be available to all hospital staff including both treatment
and pharmacy staff.” (Spector, 2019 p. 147) As an administrator, the goal to resolving this
problem of medication mistake would have been to create a checks and balances system to
ensure that the data that was being inputted in the CPOE network was precise. Nevertheless,
article Car et al., (2017) a fine balance needs to be established between technologies and
constructive experimentation that could lead to a game-changing breakthrough. (p. 73)
SOLVING THE PROBLEM AT SPRINGFIELD GENERAL
When it comes to solving a problem, they are two way in which you can look at the
problem, one being from a biblical perspective and the other being from the physical. Philippians
4:6 ESV states, “do not be anxious about anything, but in everything by prayer and supplication
with thanksgiving let your requests be made known to God.” This passage best correlates the
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CASE STUDY 1
problems that Springfield General is experiencing with the implementation of computerized
physician order entry technology. As an administrator, I would turn to God and not my own
understanding to solve the issues that my hospital is facing due to even more errors. Taking the
time to reflect on Gods words and not be anxious, while praying for a resolution to the ongoing
problem that was facing the hospital would be my best approach.
James 2:26 ESV states, “faith apart from works is dead.” So, my next plan of action in
the physical, will be to get up and do what I have prayed for which is to solve this problem using
technology. According an online publication Collier, (2014) after surveying several general
surgery residents at the University of Toronto, they discovered that sometimes new technologies
are oversold and it is up to the doctors to ask evaluating medical questions as it relates to
technology. (P. 186) Though technology is now a thing of the future and may have the best
programmers or hardware designers, does not necessarily mean that the information it is giving
out is correct at all times. According to Wu et al., (2018) development and application of medical
technologies reflect the medical quality and clinical capacity of a hospital. In addition, regulation
on medical technologies is very crucial and the primary task for the medical administrative
department to ensure the safety and effectiveness of medical technologies. (p. 1327)
CONCLUSION
The advancement of medical technology being integrated into hospital and other clinical
settings, has shown to be very valuable asset with a lot of benefits for medical advances. Though
cost will always be a factor, having the medical technology to assist in combating medical errors
will always be worth the price over the life of a human. Even though technological change often
has a cost benefits attached to it, the long term saving that the medical office, clinics or hospital
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CASE STUDY 1
will benefit from in the long run will always be worth risk. Looking back at the case of
Springfield General Hospital, the Technological change that the administrators was expecting
from computerized physician order entry, would fall on the bad side of technology integration in
to the medical sector because it increases the cost greater than the benefits due to the many
errors. In the event Springfield General Hospital had other safeguard measure in place as a safety
net to protect them from computerized physician order entry, they would have been able to
minimize their risk factor and limit the damages that was being done.
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CASE STUDY 1
REFERENCES
Björkstén, K. S., Bergqvist, M., Andersén-Karlsson, E., Benson, L., & Ulfvarson, J. (2016).
Medication errors as malpractice-a qualitative content analysis of 585 medication errors
by nurses in Sweden. BMC Health Services Research, 16(1), 431.
Car, J., Tan, W. S., Huang, Z., Sloot, P., & Franklin, B. D. (2017). eHealth in the future of
medications management: Personalisation, monitoring and adherence. BMC Medicine,
15(1), 73-9.
Collier, R. (2014). Medical technology: the good and the bad. CMAJ : Canadian Medical
Association Journal, 186(18), 1353. https://doi.org/10.1503/cmaj.109-4931
English Standard Version. (2012). https://www.esv.org/ (Original work published 1953)
Spalla, L. d. R., & Castilho, S. R. d. (2016). Medication reconciliation as a strategy for
preventing medication errors. Brazilian Journal of Pharmaceutical Sciences, 52(1), 143-
150.
Spector, B. (2019). Implementing organizational change (3rd ed.). Upper Saddle, NJ: Pearson.
Wu, S., Chen, T., Pan, Q., Wei, L., Wang, Q., Li, C., . . . Luo, J. (2018). Establishment of a
quantitative medical technology evaluation system and indicators within medical
institutions. Chinese Medical Journal, 131(11), 1327-1332.
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