OPERATIONS MANAGEMENT CASE STUDY

WRONG MEDS AGAIN

Abstract
This case study is one clear example of a processing error while transmitting a patient’s
medication list by a healthcare provider, which could have serious impacts on the patient as well
as the hospital. It also emphasizes the need for a properly designed process that can eliminate
many opportunities for errors.

Submitted to: Prof. Ayman Abu Sharkh

MGMT-6081-01-19S
July 10th, 2019

Submitted by: Priyanka Manjunatha Manjunath

Problem Statement
This case study is one clear example of a processing error while transmitting a patient’s
medication list by a healthcare provider, which could have serious impacts on the patient as
well as the hospital. It also emphasizes the need for a properly designed process that can
eliminate many opportunities for errors.

In general, a hospital is one sophisticated organization, followed by the ambulance service and
then the nursing home. A hospital organization should tend to the smallest needs of a patient
carefully and even a slight error in medication or monitoring a patient can sometimes prove to
be fatal to the health of the organization itself. The hospital should take measures to make sure
it has the patient’s updated medical history before going ahead to treat him/her.
This case is based on a situation where a distraught client puts out her frustration and
complains about the errors committed by Regis Hospital while treating her father from the time
he was picked up at the Nursing Home to the time of considering his past and current
medication list.
Assuming that the medication list was handwritten, this case is based on the following
scenarios:
- The nursing home maintains a manual record on the medications given to a patient each
day. This may be done on the handout provided by an outside pharmacy.
- The electronic file of each patient’s list is updated at the hospital at irregular intervals.
- All the transmittals of the patient’s medication records are either faxed or hand
delivered to the doctors by the nursing home. In this case, the medication data seems to
be handwritten, due to which electronic transmittal to the hospital was problematic
because of the data being recorded manually.
- Patient information is entered by the admission staff and the nurses at the nurse’s
station.
- On the hospital floor, all data is recorded and transmitted electronically on PC’s rolled in
to the patient’s room. The information would not be uploaded to the central base until
the next morning.
- Due to the poor and unreadable transmittal of the medication list at the nursing station,
the patient’s relative had to take it upon herself to drive around to the nursing home
and make several copies of her father’s current medication list.
- Even after handing out the current list of medications to the nursing staff and posting it
on the bulletin of the patient’s hospital room, the hospital had committed the error of
referring to the medication list that was prescribed by them two years ago. This means
that the patient’s data in the central base was not updated at regular intervals.
This is a process map showing various points of errors:

Nursing Home Ambulance Emergency Hospital Pharmacy

Room

Med list EMT Admission Nurse Pharmacy

prepared receives staff station receives
for the list receives receives new meds
patient list the list list

EMT takes
Med list list in List gets Doctor Correct
copied Ambulance entered reads list meds
correctly into & gives dispensed
system orders for to the
correctly new meds patient
EMT gives
List given list to ER
to EMT’s nurse
List New meds Meds
uploaded list delivered
into entered to the
system in into patient’s
a timely system in nurse
manner a timely station
manner

Nurse
administers
meds to
the correct
patient

Recommendation
This above process could be made a whole lot simpler and save a great deal of time retrieving
or transmitting the patient’s medication list if all parties used a common electronic mode of
communication. The hospital can make use of bar codes or RFID-type tags to record medical
data of the patient and dispense the proper medication. The ambulance service and the
hospital could read the tag and obtain up-to-date information about the patient being taken
care of. The map showing the revised process of treating a patient by making use of
barcodes/RFID tags is as below:

Pharmacy Nursing Home Ambulance Emergency Room Hospital

Pharmacy Med list EMT Admission Nurse

generates with receives staff scans station
patient’s barcode list barcode receives
meds list updated on and opens the new
with a timely patient’s meds list
barcodes manner history
EMT’s
retrieves
med list New meds
Med list
Meds list saved on Meds list list is
given to
sent to the system is updated
Ambulance
the and cross retrieved into the
patient’s checks on the system for
nursing system future
home reference
regularly
When
patient Doctor
is refers the
admitted meds list
to the and makes
hospital changes in
meds
New meds
delivered
to the
patient’s Nurse
nurse administers
station the correct
meds to
the patient