Dr Ellington wrote an order for 0.8 milligrams per hour of morphine Nurse Ginny Swenson explained to Patrick: Leadership Change and Innovation Management Case Study, HBS, Ireland

Dr. Ellington wrote an order for 0.8 milligrams per hour of morphine,” Nurse Ginny Swenson explained to Patrick O’Reilly, a newly hired nursing school graduate. Swenson had just wheeled Matthew, the ten-year-old patient, from the intensive care unit into his new room on the medical/surgical floor.1 She described Matthew’s condition and instructed O’Reilly to program the electronic infusion pump so that the child would receive his prescribed dosage of morphine.

Swenson then returned to her unit, leaving O’Reilly alone with Matthew. O’Reilly was not familiar with this type of electronic infusion pump, having only operated one during a training exercise. Recognizing his lack of experience, O’Reilly sought and obtained help from Nurse Molly Chen, who agreed to help him program the pump. Unfortunately, none of the nurses on the floor were accustomed to using these pumps because patients in this unit typically did not need continuously infused painkillers.

To program the pump, Chen needed to enter both the morphine concentration and the appropriate rate of infusion. The nurses did not see a concentration listed on the medication label; however, Chen utilized information on the label to calculate the concentration. See Exhibit 1 for a copy of this label. She also entered the rate of infusion at 0.8 mg per hour, as Nurse Swenson had instructed. Following hospital procedures that required a second person to double-check intravenous medications, O’Reilly verified Chen’s calculations and the settings that she had programmed into the machine.