© 2014 by the President and Fellows of Harvard College. This c.docx

© 2014 by the President and Fellows of Harvard College. This
case was written by Lina Matta, PharmD, and Mark
Bloomberg, MD, Harvard T.H. Chan School of Public Health, as
the basis for class discussion and education rather
than to illustrate either effective or ineffective handling of an
administrative or public health situation. This
publication may not be digitized, photocopied, or otherwise
reproduced, posted, or transmitted, without the
permission of Harvard T.H. Chan School of Public Health.
PH4-016
2014
Medication Management at Acme Medical Center
“This patient might have died from complications related to her
TPN infusion,” said Dr. Isaac
Johnson, Chief Medical Officer at Acme Medical Center
(AMC). His review of the root cause
analysis of a recent adverse event in medication management at
the children’s hospital within
AMC suggested that his team’s efforts to get every employee
engaged in quality improvement
were inadequate to address the complexity of care provided at a
tertiary facility like AMC.
His partner in this effort, Chief Nursing Officer Sheryl Turner,
noted, “There is a real need to
hardwire into the institution how quality improvement is to be
performed.” While the need was
evident, it was not as clear what the next steps should be.

Acme Medical Center
Acme Medical Center (AMC) was located in Middle City and
enjoyed a long and proud history.
The second oldest hospital in the state, it was founded in 1876
as The City Clinic with the
support of local business and society leaders as initial sponsors.
Since then, Acme Medical
Center grew to become a 515-bed tertiary center that provided a
complete range of medical
services to adults. Children were also cared for through its
adjacent 100-bed pediatric
institution, The Acme Hospital for Children.
Acme Medical Center was organized much like most other
academic institutions. While
independently governed, it maintained close ties with its next-
door neighbor Acme University
School of Medicine. Its salaried clinical staff was organized
into a separate faculty practice
known as the Acme Medical Center Physicians Organization.
The President of the faculty
practice reported directly to the CEO of AMC and was equal in
position to AMC’s COO, CNO,
and CFO.
In addition to its tertiary services, Acme Medical Center had a
well-deserved reputation for
serving as the local hospital for one of the city’s ethnic
communities whose urban enclave
surrounded the hospital complex. This created a culture within
which AMC staff viewed
themselves as more than a purely academic medical center,
taking great pride in fulfilling this
additional local mission. While research was fostered and
conducted on campus, the staff of

AMC appreciated having this local primary care mission and
proud of being less formal and
more relaxed than some its academic neighbors. Most of the
staff, both non-clinical and clinical,
had a long history with the institution and were strong
supporters of its mission and the care
provided to patients.
This document is authorized for use only in Kris Michaelson's
HCM520-WI17D course at Colorado State University - Global
Campus, from January 2018 to July 2018.
Medication Management at Acme Medical Center PH4-016
2
Quality Improvement at Acme Medical Center
David Herman, CEO of Acme Medical Center (AMC), set the
tone for how he hoped quality
improvement would be addressed within the hospital. His view
was that, “We can’t run from our
mistakes. We need to be fair and consistent in our approach and
need to give our staff a safe
place to recognize and respond to medical errors.”
The hospital had a patient care assessment committee, whose
duties included collecting the
details of all significant adverse events, notifying the state
medical board of their occurrence,
and then following up on any queries that ensued. To date,
quality improvement was largely left
to the initiative of each department. The long-time former
Director of QA was particularly

focused on meeting the standards of the joint commission. She
believed that quality
improvement efforts should be left to the discretion of the front-
line departments who best
understood their own processes.
Dr. Isaac Johnson had been the Chief Medical Officer of Acme
Medical Center for the last three
years. In that capacity he had responsibility for both patient
safety and ongoing quality
improvement activities. Sheryl Turner had been the Chief
Nursing Officer for the last five years
and was responsible for all of the patient care services
throughout the institution. This included
all medical and surgical units, all ancillary services, and all
ambulatory services. The CNO/CMO
partnership formed between Turner and Johnson had become a
close one. Two years ago they
initiated efforts to educate and inform their fellow senior
managers about the impact that
quality issues have on the institution and the need to create
cultural change to have a decisive
impact on safety and quality. While their fellow executives
voiced support, the cultural change
they desired had not yet materialized.
To that end, last year they established a new Department of
Quality and Patient Safety and
replaced the former Director of QA with a new person with
experience in long-term quality
improvement. Since then, AMC had established “charters”
which were formal statements of
authorization for addressing specific institution-wide quality
improvement initiatives. The first
of these was related to medication errors and resulted in better
efforts to identify all errors and

evaluate the root causes that contributed to their occurrence.
The charter outlined the system-
wide educational programs, policies, and procedural changes
that were designed to elevate
awareness of the issue and promote ways to identify all such
errors.
Both CNO Turner and CMO Johnson also wanted to extend
deeper awareness of QI and patient
safety beyond their fellow senior managers and to build a
greater commitment at the board
level. While a few initial steps were taken to do this, such as
reporting error rates and discussing
the most common and the most serious errors, almost all of the
board involvement in QI
remained based in the board’s quality committee and did not
extend to the larger board. The full
board only received a summary report on quality every two
months. Ms. Turner and Dr.
Johnson often discussed how best to develop the board as a
motivating force in QI and patient
safety, but they perceived that the board was far more
comfortable discussing financial issues
and strategic direction. Most laypersons on the board lacked a
working understanding of QI and
3

patient safety issues, and some felt that quality issues should be
left to the clinical staff of the
hospital to address.
Medication Management and Its Role at Acme Medical Center
As in other medical institutions, medication management at
AMC was considered to be an
essential component of good medical care. Several important
aspects of medication
management were actively used in AMC with the goal of
optimizing therapeutic regimens that
would improve health outcomes. These included the medication
use process (MUP) (see
Exhibit 1), evaluation of a patient’s medication regimen, and
documentation and follow-up of
therapeutic progress and adverse events. The MUP represented a
series of steps that began with
an order for a medication and ultimately resulted in the
administration of a medication to the
patient. According to the Institute of Medicine, although errors
within the medication use
process can occur at any stage, they occurred most frequently
during the prescribing and
administering stage. The details of the MUP differed between
pediatric and adult patients and
also between orders for intravenous medications, total
parenteral nutrition (TPN), and oral
medications. The MUP process for pediatric TPN is detailed in
Exhibit 2.
Ralph Rolls, Director of Pharmacy at AMC, described the
pediatric pharmacy staffing at AMC.
On a weekday day shift, there were two or three pediatric
pharmacists on the patient floor with
at least one of them actually stationed on the floor, providing

easy access to the team. On a
weekday evening shift, there was one pediatric pharmacist
available in central pharmacy and no
pharmacist on the patient floors. On the weekends, there was
one pediatric pharmacist assigned
for eight hours out of every 24 hours. This pharmacist may be
on the day or evening shift but not
the night shift. On a weekday night shift, the entire hospital
(adult and pediatric) was supported
by two general pharmacists. On the weekend night shift, the
hospital was supported by one
general pharmacist.
On weekdays the dietician, who was the expert in TPN
formulation, was available to assist
medical residents in preparing TPN orders; the resident then
wrote the actual order. On
weekends, the dietician was on-call but not on-site. The number
of TPN orders did not vary by
day of the week. All TPN orders had to be transmitted to the
outside vendor by 1 p.m., seven
days a week.
The Adverse Event
Susan was a vivacious 16-year old who was diagnosed with non-
specific colitis several years
before the event. She had been admitted to the inpatient service
a week earlier and then
discharged. Once home she began to have increasing pain and
required readmission on a Friday,
when efforts to place a peripherally-inserted central line failed.
On Saturday, Susan was taken to
the OR for placement of a Broviac catheter so she could be
maintained on total parenteral
nutrition. The line was placed without incident and TPN was

begun. Several hours later, the
nurse noticed a precipitate in the tubing and a tendency for the
line to clog. She changed the
filter but, despite multiple attempts to clear it, the central line
clogged again and became
4
inoperative. Susan had to be returned to the operating room for
removal of the clogged line and
the insertion of a new one.
When the removed clogged line was examined, it was found to
be plugged with particulate
matter that had apparently precipitated out of the TPN solution.
In addition, the partially full
TPN bag itself was placed in the medication room, and by the
next morning a precipitate had
separated and settled into the bottom of the bag. When this was
evaluated, it was discovered
that the calcium and phosphate in the TPN solution were outside
of established parameters and
had created the precipitate that caused the line to clog.
Susan recovered uneventfully and tolerated her TPN without
further incident. The clinical case
was routinely entered into the AIMS (Adverse Incident
Monitoring System) software the

hospital used to track such events and was flagged by risk
management for evaluation.
The Root Cause Analysis Process
One of the important processes used to follow up on any
adverse events at AMC was an
evaluation by the risk management staff, during which a
decision was made on whether to
undertake a root cause analysis (RCA). An RCA involved
investigating the potential causes of an
undesirable outcome, including those related to medication
errors (see Exhibit 3). Adverse
events that resulted in significant impact to a patient and/or
seemed to be a repetition of a lesser
event were normally subjected to root cause analysis to
determine the reason(s) the event
occurred. The results of the RCA were used to redesign care
processes, practices, and policies in
order to prevent future similar adverse events.
The immediate goal of an RCA was to focus on systems and
processes without emphasis on the
mistakes of an individual. The long-term goal was to eliminate
the “root cause” of the problem
or error. The process required a comprehensive and team-based
approach to the problem that
systematically investigated each step of the process. In the past
two years, over 50 RCAs had
been performed, and these had resulted in numerous procedural
changes intended to reduce the
likelihood of similar errors. Nonetheless, the occurrence of
errors continued, and the pace of
approximately one RCA every two weeks had continued
unchanged.

At AMC, all relevant team members were included in the initial
RCA and given a task list to
complete. A successful RCA should go beyond the initial
meeting, including a follow-up process
where each participant reported findings and outcomes of
changes implemented. However, one
of the participants at a recent AMC RCA expressed frustration
at the lack of timely and
comprehensive follow-up, describing the process as “untied
loose ends.”
The RCA performed following the TPN incident noted the
following:
1. On the Friday of admission, the initial development of the
TPN recipe was done by a
dietician, and a pediatric resident completed the order, but
because the initial line
placement was unsuccessful, that order was not filled.
2. The next day, the TPN was re-ordered once the Broviac
catheter had been placed, but
because the patient’s calcium had dropped, the pediatric
resident changed the order to
5
provide more of that element without the assistance of a

dietician. The new formulation
increased the calcium and phosphate concentration to a level
outside the acceptable
solubility parameters.
3. The general pharmacist who entered the order into the
pharmacy system did not
recognize the error.
4. The IV solution pharmacist who double-checked the order
failed to recognize the error.
5. The TPN solution was prepared off-site by a special-order
pharmacy; the preparing
pharmacist failed to recognize the solubility issue. The TPN
was prepared as ordered and
sent to the medical floor.
6. Because the label verified that the TPN had been formulated
as ordered, the bag was
hung and TPN started only to have it clog the central line as
noted above.
The RCA committee described these events in their report. Dr.
Johnson was now pondering
what AMC’s next steps should be to ensure that such an event
was not repeated.

6
Exhibit 1: Overview: Medication Use Process (MUP)
7
Exhibit 2: MUP for Pediatric TPN at AMC
Step 1: TPN written on paper order (on weekdays the order is
written by registered dietician,
and on weekends the order is written by a physician)
Step 2: Paper TPN order is delivered from unit to pharmacy
Step 3: Pediatric pharmacist reviews TPN order
Step 4: Paper order is then taken to IV Pharmacy team. IV room
Pharmacist #1 will enter
formulation into computer order entry (COE) and check
electrolyte balances.
Errors: If there are errors noted on the paper order, the Central
IV pharmacist must
communicate error to prescriber and to pediatric pharmacist

Step 5: IV room pharmacist #2 reviews order now entered into
the computer against paper
order.
Errors: Errors discovered at this point must be communicated to
IV Room Pharmacist #1
Step 6: Computer order then goes to outside vendor and TPN is
prepared. Vendor pharmacist
must check electrolyte composition.
Errors: Errors noted by the outside vendor should be
communicated to AMC IV room
pharmacists.
Step 7: TPN prepared at outside vendor
Step 8: TPN is delivered back to hospital
Step 9: TPN delivered manually to the floor
Step 10: Nurse scans barcoded TPN bags
Step 11: Administration of medication is documented in
electronic MAR
8

Exhibit 3: Root Cause Analysis
Level of Analysis Questions Findings Root Cause?
Take
Action?
What
happened?
What are the details of the event?
(Brief description)
Did the event pose an immediate
danger to patients or staff?
When did the event occur? (Date,
day of week, time)
What area/service was impacted?
What areas/services/departments
are participating in the root cause
analysis?
Why did it
happen?
What were
the most
proximate
factors?

(typically
“special cause”
variations)
The process or
activity in which
the event
occurred
What are the steps in the process,
as designed?
(A flow diagram may be helpful here)
Human factors What human factors were relevant
to the outcome?
(Fatigue of staff, personal problems,
unable to focus on task, critical
thinking skills needed, rushing to
complete task, substance abuse,
fatigue or stress)
Organizational
factors
What organizational factors are
relevant to the outcome?
Equipment
factors
How did the equipment
performance affect the outcome?

Controllable
environmental
factors
What factors directly affected the
outcome?
9
Exhibit 3, continued
Level of Analysis Questions Findings Root Cause?
Take
Action?
Level of
Analysis
Why did that happen?
What systems and
processes underline
those proximate factors?
(Common cause variation here

may lead to special cause
variation in dependent
processes.)
Human
resource
issues
To what degree is staff
properly qualified and
currently competent for
their responsibilities?
How did actual staffing
compare with ideal
levels?
What are the plans for
dealing with
contingencies that would
tend to reduce effective
staffing levels?
To what degree is staff
performance in the
operant process(es)
addressed?
Information
management
issues

To what degree is all
necessary information
available when needed?
accurate? complete?
unambiguous?
To what degree is
communication among
participants adequate?
Summary of Review Findings/Conclusions (include Root Causes
and Contributing Factor/s):
Running head: RESPONSE
1
RESPONSE
2
Response
Student’s name
Course number

Instructor’s name
Date
Response
Srinivas Matineni
Your response is well presented and informational. I agree with
you that net neutrality is the standardization policy that
monitors and ensure internet services providers are deliver
information to consumers at a similar speed, in spite of the
content. I would like to add the law must strike an agreement
connecting securing the private privileges of Internet specialist
organizations to facilitate security for the best interest of the
internet users.
Net neutrality progress information technology effectiveness as
it facilitates the people or organization to recognized worldwide
commerce and successfully offers services for their customers.
I like the way you have provided that the provided restriction of
the internet service providers will lead to slow speed internet
and crash which come with negative impact to the business. You
have incorporated various practical examples in your response
which signifies critical thinking ability which is commendable.
Patrik Khator
I love the way you have introduced your response with a clear
and comprehensive explanation of net neutrality as the directing
rules that tries to control and standardize the internet service
provider activities. I concur with you that net neutrality will
utilize the first-in-first out mechanism of receiving and
redirecting the data without bias of the size or source which
ensure equality in service provision. I would like to add that the
net neutrality needs to consider that the move will attract high
traffic for the given bandwidth which increases the chances of
spam and infection. The Federal Communication Commission
(FCC) needs to protect its client and the public and ensure that
proper strategies for or against net neutrality is developed
effectively. I agree with you that without net neutrality the

internet services providers can block, slow down or back off
access to sites they don't care for which is not fair and just.
Your response is systematically presented and directional. Keep
up the good work.
References
Hahn, R. W., and Scott, W. (2006). The economics of net
neutrality. The Economists' Voice 3.6
K, Jan., Lukas, W., and Christof, W. (2013). Net neutrality: A
progress report. Telecommunications Policy 37.9: 794-813.
Net Neutrality: Myths and Facts |." American Civil Liberties
Union. 22 Sept. 2006. Web. 17 Dec. 2009.
Net Neutrality: Media Discourses and Public Perception by
Quail, Christine; Larabie, Christine. Global Media Journal,
suppl. International Perspectives on Network Neutrality,
Canadian edition.

Introduction
Product idea generation is the process that involves an
individual, a group of people or business organization coming
up with business ideas that they are ready to invest in and
establish a running business i.e. they must be ready to
implement it so that it can materialize. These ideas are usually
generated from different sources depending on some key
factors. Sources for product ideas include market gaps, research
work, hobbies, changes in quality and quantity of goods
produced, from the trending phenomena among many others.
After the idea is generated one will have to think critically
about how to implement it, since for any business to run capital
must be available, resources and other fundamental inputs.
The Product
After thorough and intensive research, consultations and
brainstorming it was found out that there are plenty of business
that one can venture into. However one has to go for the best
idea since it is assumed that the individual wants to establish a
running business out of the idea very soon.
Therefore the best idea was to venture in was to start a beauty
shop for selling cosmetic accessories. The business will be

selling perfumes, body oils and all related beauty stuff that is
used by both men and women.
The products to be sold will be majorly from within the country
and outside the country in order to cater for the local and
international customers since all customers are different. Some
will want a touch of class hence will prefer exported goods that
the locally available on the other hand we have the middle-class
customers that won’t spend extravagantly to get the products.
In addition, the products will range from perfumes, body oils
and other beauty stuff that can be used by both men and women
of all ages.
There are many benefits for example, the customers will not
have to get deep into their pockets to get the products since they
will be sold at an affordable and a lower price compared to what
other companies sell their products and The customers will have
the freedom of testing the perfumes before buying them hence
they can be sure of getting what they want and also The
customers will be given free gifts if they buy more than one
product from the business and they are given the freedom to
select what the gift will be they will have a special type of soap
that is made by the business itself that is herbal hence can help
fight all skin diseases. Lastly, if the customer happens to buy
any type of artificial hair she can be fixed freely by the
employees in the organizations.

Potential Customers
As stated earlier the products will be available for all people
who are beauty and fashion lovers both men and women
products will be available. Therefore the customers for the
products will cut across all the people.
Marketing Strategies
The business will adopt cheap methods of advertising since it is
still at its tender ages. It will use the social media platforms e.g.
Facebook and Twitter to reach out to customers and get their
feedback. Secondly, the business will develop an official
website that is going to have all the products posted together
with their prices and customers can buy the products online.
This website will have a search tool that will make it easy for
customers to search for the goods they are looking for. The
third possible way will be an application being designed to be
specifically dealing with the organization’s products, however,
this is very expensive.
Advantages
Attracting new investors and Increased advertising for the
products. Strong and solid relationship with the customers will
be established. Attracting new customers and finally, the ease of

buying the products is facilitated through the above strategies.
Disadvantages
These strategies require high capital investment in terms of
finances this could affect the business and it’s not well
established.
Recommendation and Conclusion
It will be good if the business opts to use social media for
marketing since it’s cheap to open the accounts and run them
without hiring additional employees. Lastly, the business will
have to be very assertive and active in the market so as to
capture more customers since it’s new.
References
Bitzer, B., & Biernatzki, R. (2004). Product service engineering
- from idea generation to market launch. Aachen: Shaker.
Wheelie Deals. (2016, January). Getting ready to create a

marketing plan? Retrieved February 20, 2018, from
https://www.mplans.com/bicycle_wholesaler_marketing_plan/m
arketing_strategy_fc.php
Ottosson, S. (1983). Guided product idea generation. Omega,
11(6), 547-557. http://dx.doi.org
Introduction
Women segregated gym is an open or enclosed place where only
women go for physical exercises - and no men allowed. To some
people this may sound discriminative at first, but it is not. The
idea will open an excellent opportunity for most women to
exercise and feel more secure and comfortable in a gym where
men are not around. Most women feel shy and guilty of
exercising when men are around due to their body appearances,
abilities and other personal issues. Women are also open to
trainers, and receive best advices about their health conditions
and their workout plan.
Product/Service description and benefits
The service includes setting up fully equipped gym that will
only target women who are more serious about shaping their
health and exercise routines. The segregated gym will cater for
religious and cultural factors where women of certain religion
and cultures are prohibited to exposing too much of their bodies
to men. For example, Muslim women are not supposed to

expose some parts of their body to men. In some cultures, for
example in Africa, it is a taboo for women to expose too much
of their bodies to men hence segregated gyms will help women
to freely exercise.
The gymnasium will open up a chance for many women
especially those who were bullied abused when they were young
by the opposite genders. Such women will feel free and secure
when exercising in a men free gym. This gym will therefore
attract more clients.
It is sometimes true that women act differently when around
other women. Therefore, it is important to have a segregated
gymnasium where women focus to work out with a lot of
concentration on how to lose weight and /or improve their
looks, rather than seeing the men they like and so forth.
A segregated gym is a way to bring the female gender into the
game and unchain them from oppressive cultures. This helps
them to participate in sports like acrobatics, gymnastics, and
martial arts.
Potential Customers

Plump women
Women who are basically fat to tend fear being judged by men
about their body fitness and flexibility. Some say that 80% of
women do not visit the gym due to fear of what others think of
them. The segregated gym will be a good opportunity for such
women to feel free and comfortable.
Young and shy women
Some young ladies, feel very uncomfortable when around men
due to fear of being approached. They are also ashamed of their
body changes during adolescent stages; hence feel
uncomfortable when stared at by men. A women only gym will
be an attractive place to start with for this group.
Pregnant women
Pregnant women also need a secure and comfortable place
where they can exercise at their own pace, and free from men
who like staring at women.

Ways to market a product/service
Use of Face book ads and strategically targeted landing pages
Face book is one of the most growing social sites to market
product and services. While not free, the face book ads offer a
great deal for reaching the right demographic for a business. As
long as we understand our target customers, we can use metrics
like gender, age, sex and geographic location to strategically
landing pages.
Face book ads are affordable for any size of the business. They
are also easy to use and maintain.
However, Facebook ads require one to have a good follow up
strategy so as to be successful.
Marketing through video clips on YouTube
Focusing on creating useful video adverts will eventually make
one reach a vast amount of people. YouTube gives a smart
platform for marketing your business on the internet. Targeted
customers can easily access and watch the videos, get interest
and join the gymnastic program.

Advantages: The method is viral. It reaches many people at a
very short duration.
Disadvantages:
Low security when it comes to adverts and high weight time.
YouTube cannot protect or safeguard the business against
illegal content.
Creation of a blog where regular content is posted,
This is the most important way to market one’s product and
services. It’s a long term strategy although very helpful to
create awareness to potential customers.
Blogs allow direct and timely communication, increase
openness and they are cheap to be used and accessed by the
target very easily.

The demerits of using blogs are that they might attract legal
problems to a business.
Use of local radio and televisions
Use of local radio and television, this is another method that
allows reaching a vast number of women interested in the gym.
It is very efficient since the method can reach many people at
the same time.
The advantage of using this method is that it reaches a large
number of people and attaches a visual personality to a
business. It also reaches the audience at a time when they are
most attentive.
Using television and radio has a number of disadvantages too;
the method is expensive and its difficult to correct errors and
make changes. Also the advert can miss the targeted audience.
Email Marketing
Email marketing is very valuable as long as products and
services are concerned. It is the most effective channel for

acquiring new customers. Email marketing starts working right
away that’s why it can be used to promote one’s business.
Use of email marketing. This service works very fast and
potential customers get email at regular basis. Example, when
the update of a product or service is available.
The disadvantages of using email marketing to advertise
products and services: The method is not easy to feat. To
succeed, one needs to give something valuable. Also one need
to record the emails of all potential customers in order to send
them emails at regular basis.
Conclusion
A gender-segregated gym will ensure that women feel
comfortable, and are helped to achieve their healthy life and
fitness goals.
References
Robinson, D. B. (2013). Getting girls in the game: Action
research in the gymnasium. The Canadian Journal of Action
Research.

Rosenblum, K., & Travis, T. M. (2015). The meaning of
difference: American constructions of race, sex and gender,
social class, sexual orientation, and disability. McGraw-Hill
Higher Education.
Thul, C. M., LaVoi, N. M., Hazelwood, T. F., & Hussein, F.
(2016). A Right to the Gym. Child's Play: Sport in Kids'
Worlds.
Rana, J. (2017). Ladies-only! Empowerment and comfort in
gender-segregated kickboxing in the Netherlands. In Race,
Gender and Sport.

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