HLTH 2120 Week 10 System Change Implementation Memo Example

Memorandum

To: Director of Nursing, Emergency and Medical-Surgical Services; Pharmacy Manager; Clinical Informatics Lead

From: Informatics student intern

Date: Month Day, Year

Re: Sequence, training by role, first-week support and fallback plan for the measured-weight requirement approved at the safety committee

Purpose

The safety committee has approved the modified measured-weight change: whenever an adult in the emergency department or on a medical-surgical unit has a high-alert medicine ordered at a dose set by body weight, the system will require a weight measured in kilograms during the current visit, or a documented reason the patient cannot be weighed, before the order can be verified by pharmacy. Two additional bed scales have been purchased for the emergency department. The change follows medication safety guidance that patients be weighed in metric units as early as possible (Institute for Safe Medication Practices, 2024). This memo does not revisit the decision. It sets out how the change will reach the staff who must use it: the sequence of steps, training by role, support during the first days and what happens if the rollout does not go as planned. Research on large health information technology implementations stresses that technical build is the smaller part of the work, and that preparing users, supporting them at go-live and monitoring for problems determine whether a change is adopted (Cresswell et al., 2013).

Sequence

Weeks 1 and 2: build and test. Informatics builds the requirement in the test environment. Pharmacy and two emergency department nurses test ten scripted scenarios, including a patient on a stretcher, a patient who cannot be weighed and an order placed before arrival on the unit.

Week 3: equipment in place. The two new bed scales are placed in the emergency department, labeled with their locations on the unit map and checked by biomedical engineering.

Week 4: training (see below).

Week 5: go-live on a Tuesday. Tuesday avoids the weekend, when staffing is thinner, and Monday, when the emergency department is usually busiest.

Weeks 5 to 8: monitoring and adjustment.

The sequence puts equipment before training so that staff learn the change with the scales already in place, and training before go-live so that no one meets the requirement for the first time with an order waiting.

If testing in weeks 1 and 2 finds a scenario the build handles badly, go-live moves back a week rather than going ahead with a known problem.

Training by Role

Emergency department nurses. A ten-minute huddle segment, repeated on all shifts over five days: where the new scales are, how to record the method field and how to document a reason when weighing is unsafe. The message to emphasize is that the stated-weight option still exists for patients who cannot be weighed, so no one needs to mislabel an estimate as measured.

Medical-surgical nurses. A five-minute segment: the requirement now applies on their unit for patients who arrive without a measured weight, and the admission weigh-in for other patients is unchanged.

Pharmacists. A short written guide and a demonstration at the pharmacy staff meeting: what the new verification screen shows and how to handle an order held for a missing weight.

Emergency department technicians. A brief walk-through of scale locations and cleaning between patients.

Prescribers. A message from the medical director explaining why a weight-based order may wait for verification, with a one-line description of the exception.

Support During the First Days

During the first five days after go-live, an informatics nurse will be present in the emergency department from 1500 to 2300, the busiest admission hours, and on call by phone overnight. A pharmacist will review every held order each morning to check whether the hold was appropriate. A simple form at each nursing station will collect problems, and the informatics lead will review it daily and post short answers at the huddle. These at-the-elbow arrangements matter most in the first days, when staff are most likely to adopt workarounds if the system blocks them and nobody is there to help.

Measures and Fallback

Three measures will be checked weekly for four weeks: the share of weight-based high-alert orders verified with a measured weight; the number of orders held more than 30 minutes for a missing weight; and the share of measured weights entered by method in the emergency department, compared with the baseline audit. A rise in the third measure without a rise in bed-scale use would suggest that estimates are being mislabeled as measured, the workaround the workflow analysis predicted (Campbell et al., 2006).

Fallback. If more than five orders in any day are held longer than 30 minutes, or if any patient's high-alert medication is delayed in a way the medical director judges clinically significant, the informatics lead may switch the requirement from a hard stop to a warning that pharmacy reviews, without waiting for a committee meeting. The committee will then decide whether to restore it after fixes. Having a pre-approved fallback means a problem on day two can be handled the same day, rather than leaving staff to work around a failing rule until the next meeting.

References

Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2006). Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association, 13(5), 547-556. https://doi.org/10.1197/jamia.M2042

Cresswell, K. M., Bates, D. W., & Sheikh, A. (2013). Ten key considerations for the successful implementation and adoption of large-scale health information technology. Journal of the American Medical Informatics Association, 20(e1), e9-e13. https://doi.org/10.1136/amiajnl-2013-001684

Institute for Safe Medication Practices. (2024). Targeted medication safety best practices for hospitals. https://www.ismp.org/guidelines/best-practices-hospitals