N5308 The University of Texas Clinical Error Workflow Design & Analysis Project

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Workflow Design & Analysis Project

A workflow design is a diagram illustration of the actions and steps in a prescribed sequence. Workflow design is used to show steps of a process. In this project, we will analyze a scenario, create, and analyze a workflow design.


A patient calls using the patient call system to request medication for nausea. The unit clerk communicates this request verbally to the nurse. The nurse remembers that the physician ordered Ondansetron (Zofran) IV PRN for nausea. The nurse goes to the medication dispensing system and enters the correct patient name. The nurse searches and locates Ondansetron (Zofran) in the system directory. The correct drawer opens with all of the medications in the drawer available in view. The nurse takes the medication from bin #2 thinking this is Ondansetron (Zofran) as that has always been the location for that medication. In reality, an incorrect medication was taken from the dispensing system. While in the medication room, the nurse receives a phone call from the unit clerk that another patient is requesting assistance with their IV site. The nurse closes the drawer of the medication dispensing system and logs out of the system. The nurse takes the medication to the patient and administers the medication IV for what is presumed to be Ondansetron (Zofran). Due to the urgent need of another patient, the nurse chooses to complete the documentation at a later time.


1. Read the Scenario and the assigned readings

2. Review the grading rubric

3. Review the literature and cite a minimum of 3 scholarly articles. You may include your textbook as an additional resource.

4. Written paper submission to include:

A. Cover page (Use APA format)

B. Content of the paper with the following headings:

Scenario Analysis- Based on the scenario presented, include the following content.

(Note: Do not re-copy the scenario in your paper.)

– Describe the errors that occurred in this scenario

– How many people or departments contributed to the errors in this scenario? Explain

– Were the issues attributed to system or human error? Why?

– Explain the barriers to the human-technology interaction noted in the scenario

– Explain the importance of the human-technology interaction

Workflow Design Analysis- Based on your workflow design diagram form Appendix A, include the following content

– Describe the key areas of your workflow design diagram

– Describe the focus of your process- technology, clinical staff, patient, or a combination? Explain

– Identify and describe at least 2 barriers and/or challenges to making any workflow and system changes

– Discuss methods to address and overcome these barriers/challenges

C. References (separate page)

D. Appendix A: Workflow Design Diagram

– Create a Workflow Design (process flow) diagram in Microsoft Word, Microsoft Visio or some other type of software showing the correct process for medication administration.

– You must include a variety of flowchart shapes, lines, arrows, and/or connectors as noted in the Flowchart Shapes document (see the link below). A sample workflow design is provided for you (see the link below).

Show the points/locations (using color or symbols) in the process indicating where humans and technology intersect

– Include a legend or key to describe the colors and intersections

– Place the diagram after the references, as Appendix A in your written paper (refer to the APA text). Your diagram must be included within the Word document. You may need to copy and paste your diagram into your paper. Papers are only accepted in word document format. Separate attachments are not accepted.

E. Max 5 pages (Not including cover page, reference page, or appendix with workflow diagram)


Reading #1- chapter 10, 13, 14, 16 and 17 of McGonigle, D. & Mastrian, K.G. (2018). Nursing informatics and the foundation of knowledge. (4th Ed.). Burlington, MA: Jones & Bartlett Learning.


Workflow Design_McBride & Tietze