Introducing the Case

Medication mistakes — also called adverse drug events — are a major problem in US hospitals. The most common error is handwriting identification. Springfield General Hospital im plemented the Computerized Physician Order Entry (CPOE) system as a way to fix the problem. The result was an increase in adverse drug events.

1. What went wrong? How can you explain how the technology actually led to more rather than fewer mistakes?

2. What theories of change implementation would have helped the administrators at the Springfield General Hospital solve the problem of medication mistakes?

3. How might you have gone about solving the problem at Springfield General? To what extent, if any, would new technology have been helpful?