HLTH 2120 Week 9 Workflow Change Analysis Example

Who Pays for a Measured Weight? A Workflow Analysis of Moving Weighing Upstream to the Emergency Department

Student Name

Walden University

HLTH 2120: Health Informatics

Instructor Name

Month Day, Year

Who Pays for a Measured Weight? A Workflow Analysis of Moving Weighing Upstream to the Emergency Department

The Proposed Change

The data quality audit earlier in the course found that most stated weights and both unit errors entered in the emergency department, and that six patients received a first weight-based dose before any measured weight existed. The proposed change responds directly: for every adult whose admission from the emergency department is headed to a medical-surgical bed, a measured weight in kilograms must be recorded in the emergency department before the bed request can be submitted, with an exception for patients who cannot be weighed safely, which requires a reason. The change saves somebody time and hands work to somebody else. This analysis traces that transfer, names the roles absorbing it and asks whether the trade is worth making. Times are estimates from observation and staff interviews in a composite setting and are illustrative.

The Workflow Before the Change

Today, the emergency department triage nurse asks the patient's weight or estimates it and types it into a single box that defaults to pounds. Most patients are not weighed in the emergency department, because the department has two standing scales, one in triage and one in a hallway, and one bed scale shared across 30 rooms. When the patient reaches the medical-surgical unit, the admitting nurse is expected to weigh the patient, using a bed scale or a standing scale on the unit, and enter the result in the admission flowsheet. On busy nights, that weight is often delayed by several hours or replaced with the triage value, and the pharmacist verifying a weight-based anticoagulant order works from whatever weight exists, frequently the triage estimate.

The result is that the first weight many pharmacists see is the one least likely to be accurate. The audit found this pattern in six of 60 admissions, and in each the first weight-based dose was calculated before a measured weight existed. That is the problem the change is meant to solve.

Where the Work Moves

Table 1 traces who gains time and who absorbs it under the change.

Table 1

Estimated Transfer of Work When Weighing Moves to the Emergency Department

Note. Times are illustrative estimates for a composite hospital.

Who Absorbs the Cost

The emergency department absorbs the cost, and it absorbs it at the worst point in its workflow: when a patient is admitted and waiting for a bed, the department's nurses are usually also caring for new arrivals. Adding five to ten minutes per admitted patient, on a night with 20 admissions, adds up to two or three hours of nursing time the department does not have. The bed request requirement also creates a hard stop, and studies of computerized order entry describe how hard stops placed where staff are under time pressure produce workarounds and new kinds of errors (Campbell et al., 2006). The likeliest workaround is easy to predict: entering the stated weight with the method set to measured, to release the bed request. That would make the data worse than today, because the false label would hide the estimate. It is the same pattern seen with barcode scanning, where staff under pressure find quick ways to satisfy a required step (Koppel et al., 2008).

The medical-surgical unit and pharmacy gain. Their gain is real but spread out, a few minutes per admission and fewer phone calls, while the emergency department's cost is concentrated during its busiest moments. This pattern is common in health information technology: benefits appear downstream, costs appear upstream, and the people asked to change their work are not the people who see the benefit.

Naming the absorbing role is the first step toward a fair design, because it shows whose time the change must protect.

Is the Trade Worth Making?

As proposed, no. The safety goal is sound, and guidance on medication safety supports weighing patients in kilograms as early as possible (Institute for Safe Medication Practices, 2024). But a hard stop on the bed request places the whole cost on the emergency department at its busiest moment and invites a workaround that would corrupt the data the change is meant to improve.

A modified version would be worth making. First, buy two more bed scales for the emergency department, which removes most of the search time that makes weighing slow. Second, replace the hard stop on the bed request with a requirement that applies only when a weight-based high-alert medication is ordered, which concentrates the effort on the patients for whom the measured weight matters most. Third, keep the unit's admission weigh-in for everyone else, so that the unit's saving is smaller but the emergency department's cost falls on far fewer patients. Under this version, the emergency department absorbs perhaps a quarter of the original cost, the pharmacist still gains on the orders that matter and the incentive to falsify the method field mostly disappears.

The general lesson is that a workflow change should be judged by where its costs land and when, not only by whether its goal is good. A good goal placed on the wrong role at the wrong moment produces workarounds, and workarounds can leave the data worse than before.

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

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

Koppel, R., Wetterneck, T., Telles, J. L., & Karsh, B.-T. (2008). Workarounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15(4), 408-423. https://doi.org/10.1197/jamia.M2616