Case Introduction:

This case examines clinical processes, systems, and controls associated with administering medications.
The case set at “Compassionate Care Hospital of New England” (disguised) is positioned from the point of
view of a hospital’s vice president of administration (“Sandy Payne”). Students also have an opportunity
to consider the viewpoints of the CIO (“Henry Sharp”) and medical director (“Sudha Mehta”). Sandy Payne,
who worked as a nurse on a neonatal intensive care unit (NICU) earlier in her career, learns that an infant
at another hospital’s NICU has died after being inadvertently overdosed with blood thinner. Thinking
about this and similar incidents, Payne realizes that the risk of a similar tragedy occurring at her hospital
is high. She reflects on what she learned about process modeling and control analysis in her management
courses, and whether these techniques could be used to help reduce medication dosage errors at
Compassionate Care. The hospital is already participating in some US national patient safety initiatives,
but she believes there is room for further improvement.

The case is desifned to help students recognize that the analytical skills they acquire in one domain
(identification of control strengths and deficiencies as applied to financial data and business processes)
may, with appropriate modification, be applied in other domains (such as healthcare). By taking
students out of their accounting comfort zone, we hope to sharpen their critical thinking skills.

Learning Objectives:

1. Introduce students to the significant and widespread problem of medication errors, in the
broader context of healthcare quality improvement initiatives.
2. Develop students’ critical thinking skills by requiring them to apply techniques from one domain
(Accounting Information System / AIS) to another (healthcare quality improvement); specifically,
to:
a. correctly interpret a system flow chart describing an operational process and associated
databases and applications, and modify it to reflect proposed changes.
b. prepare a control matrix identifying existing controls, and map it to the flow chart.
c. drawing on the above analysis, identify control strengths and deficiencies in the as-is
(current) process.
d. offer recommendations to improve processes and related information.
Guide questions:

Instructions:

1. Research on items 1 and 2 and bring a hard-copy of what you researched. We will have a group
activity discussion next meeting.
2. Have a preliminary analysis on the controls as stated in the case with questions 3 and 4 as your
guide.

Expected Output:

Meeting 1: Research on items 1 and 2

Meeting 2: Individually made process flowchart.

Meeting 3: An individually made Control Matrix.