Medication Errors Case Study Essay

As the Making the Problem Worse case study noted, medication errors and medication reconciliation is vital to the success of a hospital in today society. In order to improve on their mistakes, the leadership team decided to implement a technology called Computerized Physician Order Entry (CPOE). The research stated that a reduction in errors and cost would be captured if this system was implemented, however, the hospital did not realize these results. How could this be true? The following essay will describe some of the reasons why this may have occurred.
The trigger event which prompted the needed for change was the external environments attention to medication errors. Specifically, the newspaper article that came out on Thanksgiving Day. …show more content…
If the organization could have role played some of the new skills required, such as with the 3 point check or utilizing the CPOE system, the employees would have developed new behaviors and skills. For example, they could have created mock patient in the system and practiced entering the usual doses, as well as, finding best practice to not choose the wrong patient as the font was small. Or in simplest form, a lecture/discussion could have been utilized to show that hand written orders were illegible and causing the problem. Additionally, the hospital could have developed better coordination and teamwork among people such as nursing, pharmacist, and physicians, as they would have received feedback not only from their managers, but their coworkers as well. This was have ensured that the information learned would have been utilized in the ongoing future (Spector, 2013, p. 104). The hospital may have went astray when they did not ensure they had the appropriate people on the bus, as noted in stage 3, people change. The organization could have provided the aforementioned training as anyone can learn new skills, however, the organization may have needed to view if the employees can develop or adapt to the new values of the organization or new person-organization fit. It is

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