Running head: CHILDRENS HOSPITAL AND CLINICS CASE STUDY

Childrens Hospital and Clinics

A Case Study Write-Up
Maria Almacen
MMI 404-DL
Northwestern University
May 4, 2014
CHILDRENS HOSPITAL AND CLINICS CASE STUDY

Introduction
Childrens Hospital and Clinics (Childrens) is a primary care healthcare organization.
Julie Morath (Morath) was appointed COO in May 1999. Morath focused on patient safety as her
top priority. Her Patient Safety Initiative (PSI) resulted in blameless reporting, frontline
focused event analysis, good catch logs, improved Patient Safety Report, Medication
Administration Project (September 1999), and a new disclosure policy governing
communications with parents regarding medical accidents. In January of 2001, a ten-year-old
patient named Matthew (who was transferred from the intensive care unit to a medical-surgical
floor) experienced an adverse drug event (ADE) due to drug labeling errors. The concentration in
the label was visually hidden and the drug dosage indicated in the syringe was also confusing.
Success of Julie Moraths Program
Moraths program appears successful in how she employed transformational leadership.
She effectively communicated the urgency for change by emphasizing that patient safety is top
priority. Morath used forums to gather feedback and ideas from the clinical staff, ancillaries,
patients, and patients families on how to improve patient safety. She knew the imperatives of
promoting a culture of no blame to encourage an atmosphere of unimpeded sharing of
experiences with medical errors. She also identified the barriers to implementing change and
worked around them by discouraging the use of offensive words, opting for terms that promote
positive engagement among the clinical staff. This atmosphere of openness encouraged the
formation of Safety Action Teams that led to the good catch log initiative, which provided a
way to identify potential patient safety issues. There are, however, some setbacks. The benefits
of the new complete disclosure policy are vague as efforts to measure its effectiveness remain
unaddressed. Others criticized it for undermining Childrens legal risk profile by unnecessarily
volunteering information detrimental to Childrens legal interests. Further, the Medication
Administration Project appears to be ineffectual on account of Matthews ADE, which involved a
physician and nurses handing off medications. Somehow the improvements in the medication
administration process failed to appropriately guide the clinical staff about safe drug
administrations. Ultimately, the overall success of Moraths patient safety program will remain
uncertain due to its failure to measure effectiveness and its inability to provide hard numbers that
clearly illustrate the financial advantages of her program.
Justification of Continuation
Any board member will embrace the positive transformational change Morath had
introduced. She helped plainly put forth the importance of patient safety in any strategic planning
for any healthcare organization. As a healthcare service organization, Childrens first duty is to
do no harm. And while there are no hard numbers to measure the programs success in all areas,
there are also no hard numbers showing any overwhelming financial and legal risks about the
program. Patient safety improvement remains a primordial concern for any healthcare
organization as it is synonymous with its core commitment to provide quality care. The Board
may allow the program to continue but with an end date and a set of unequivocal measures of
performance to reassess its progress in order to gain a better understanding of the programs
accomplishments and their effects on the organizations clinical care and financial state.
Role of informatics in preventing Matthews Event
The role of informatics was not indicated in the case study. Information technologies
(IT) such as computerized physician order entry (CPOE), automated dispensing, barcode
medication administration, electronic medication reconciliation, and personal health records are
vital components of strategies to prevent medication errors. In this case, a clinical decision
support system (CDSS) to assist in the provision of smart pumps could have prevented the error.
A smart pump that provides a list of premixed drugs that will enable the nurses to select drug
concentration may have resulted in a much better outcome. The medication administration record
(MAR) can also help indicate the correct milliliter (ml) per hour to deliver, a critical resource for
safe drug administration.

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Challenges in Informatics Efforts at Childrens Hospital

The most obvious reason for Matthews ADE is that MAP failed to correctly provide the
nurses with essential dosage information in administering the drug. MAP informatics efforts did
not involve close coordination and constant collaboration with technology staff, no medical
informaticists acting as conduits between technical and clinical staff in building the infrastructure
and solutions for medication administration, no measurable set of goals, and use the of broad
mandates like zero defect. Further, Moraths lack of technical or informatics background may
have prevented her from appreciating the importance of employing technology in medical
informatics to properly gather, organize, measure, analyze, and deliver critical data to frontline
clinical staff. A PSSC co-chair with technology training and experience to oversee the PSI
technical implementations, including the MAP solution, could have made a difference in
preventing Matthews ADE.

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References

Edmondson, A., Roberto, M. A., & Tucker, A. (2001). Childrens Hospital and Clinics (A) [].
Harvard Business Review