Making the Problem Worse
Case Study Three
Adverse Drug Events (ADEs) are injuries occurring from drug-related medical intercessions and ADEs can happen in any health care facility to include inpatient, acute care, long term care, outpatient and nursing homes facilities (Office of Disease Prevention and Health Promotion, 2015). The Office of Disease Prevention and Health Promotion (ODPHP) (2015) provide statistics that one in three of all hospital stays in the United States incur an ADE. Moreover, that equates to two million hospital stays each year that are prolonged 1.7 to 4.6 days. Outpatient settings ADEs account for 3.5 million physician office visits, an estimated 1 million emergency room visits annually, and approximately 125,000 hospital admissions (ODPHP, 2015). Given these staggering statistics and the United States increasing population, medication introduction affords the probability for injuries from ADEs, which constitutes a perilous patient safety and public health crisis (ODPHP, 2015).
ADEs stemmed from prescribing errors, confusion over drugs with similar names, inadequate attention to the synergistic effects of multiple drugs, and patient allergies (Spector, 2013). The predominant factor contributing to over 770 million patients annually was illegible handwriting (Spector, 2013). This not only effected patients physically but financially as well driving the health care costs by several billion dollars a year (Spector, 2013). SGH saw a need to implement a change and introduce technology to assist with preventing and eliminating ADEs. The author will discuss what went wrong with the new technology, what theories of change implementation would help solve the problems, and finally the author will provide alternatives and recommendations.
What Went Wrong
SGH employed a software development company to supply SGH with a Computerized