The chief administrators at the Springfield General Hospital (a disguised name), a large urban teaching hospital, were determined to use technology to solve a nagging and disturbing problem: medication mistakes.

The Problem: Prescribing errors, confusion over drugs with similar names, inadequate attention to the synergistic effects of multiple drugs and patient allergies—those and other related errors that are lumped together under the label “adverse drug event”—kill or harm more than 770,000 patients annually in U.S. hospitals. In added health care costs alone, adverse drug events add several hundred billion dollars a year. And the most common type of error—the simplest to understand and, seemingly, to correct—is “handwriting identification”: poor or illegible handwriting by the prescribing physician.

Use these questions as a guideline for the case study.

1. 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?