This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
"Culture eats Strategy for Breakfast" -Glyn Elwyn
Notes:
Culture of changes in workflow...
Hundreds of hours invested in preparing, reviewing, education and practicing workflows.
Necessity or personal decision drove a need to "regress" or "ignore" these workflows...
Impact was errors in pharmacy charging—through charge on dispense and charge on admin.
Lost appreciation for change in scope of action of data...
Previous Slide Contents Next Slide 