Workflow Design Analysis Paper

Workflow Design Analysis Paper



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 journal articles.Additional references may include the course textbook and other sources (such informatics websites)
  4. Written paper submission to include:
  5. Cover page (Use APA format)
  6. 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

  1. References(separate page)
  2. Appendix: Workflow Design Diagram

– Based on your practice in Module 1: Create a Workflow Design (process flow) diagram in Microsoft Word, Microsoft PowerPoint, 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 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.

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



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.

Note: If you create the workflow design in the same paper as your written content for the assignment, then you may not need to practice these steps.

Flow sheet example:






Errors that occurred in the Scenario

            There are numerous errors made in the scenario by the health professionals involved. The professionals failed to follow the necessary steps taken in drug administration for the safety of the patient. The first error was a lack of documentation. The request by the patient is communicated verbally to the nurse making proper follow-up and accountability difficult. The nurse also failed to update the prescription after administering medication to the patient. Another error was the failure to communicate or consult the physician about the patient. The nurse administered a drug previously prescribed by the physician to another patient. Ondansetron (Zofran) IV PRN is linked to initial or repeated emetogenic cancer therapy. The nurse did not review the medical records of the patient. The prescription may not fit the patient in the scenario. The third error is the failure of the nurse to confirm the drug taken from bin #2 as they assume that the drug is correct given that is the location of the prescription. The errors led to nurses administering wrong medication and no proper record of facilitating error identification.

People Or Departments Contributed to The Errors in This Scenario

            Two people and three departments contributed to the errors in the scenario. The clerk contributed to the error first by relaying information verbally rather than communicating through proper channels such as an email. The nurse also contributed to the error by failing to consult the physician in charge of the patient’s care. The nurse failed to follow the appropriate steps in prescribing and administering drugs. The pharmacy department is also at fault as the drugs were labeled incorrectly. The labeling of the drawer did not match the contents of the drawer. The administrative department and the human resource department also contributed to the errors in the scenario due to the high workload, which can be linked to staff shortages. According to Ahmed et al. (2019), perceived causes of medical errors include miscommunication, high workload, low adherence to safety guidelines, and poor collaboration. The nurse is overwhelmed and postpones documentation to offer care to other patients. Poor collaboration is evident in the failure of the nurse to consult the physician. If every party had played their role effectively, the errors would have been avoided.

Whether the Issues Attributed to System or Human Error

The errors in the scenario were attributed to both system and human errors. The system of the facility seems inadequate to provide errors. For example, the nurse prescribed medication without consulting the physician. The mode of communication is also faulty as the clerk made patient requests verbally. This can be attributed to the lack of proper policies and procedures to guide the actions of the health professionals working in the facility. The issues can also be attributed to human error as the professionals involved lack accountability at the individual level. In the scenario, the nurse fails to document the drug administered to the patient and decides to do it later. They also fail to confirm the drug or make consultations before making the decision on the choice of the drug and administration mode. One of the goals of the Joint Commission is to achieve correct and safe use of medication through double-checking the labeling of drugs (Rodziewicz, Houseman, & Hipskind, 2021). This was not the case in the scenario.

The Barriers to The Human-Technology Interaction Noted in The Scenario

            Human-technology interaction can be described as a multidisciplinary field of study that focuses on the design of computer technology and particularly the interaction between computers and users, who are human beings. In the scenario, there are various barriers to human-technology interaction. If the technology is not user-friendly, the risk of errors increases. This is the case in the scenario. The nurse searches for a drug in the system directory and successfully locates it, but the system opens with all the drugs available in the view. The nurse picks a drug from bin #2, thinking it is the correct drug since that has always been the location of the drug. It is challenging for the nurse to identify the correct drug. It would have been more effective if each drawer had a particular drug and opened at a particular tie, reducing any confusion. The design of the system is also a challenge. The nurse is able to log out of the system without documenting any information related to drug administration to the patient. A more efficient system should not make the log-out possible with proper documentation.

            The Importance of The Human-Technology Interaction

            Human-computer interaction entails designing, evaluating, and implementing interactive computer systems for the usage of human beings. Human-technology interaction in healthcare is important in the delivery of safe and effective care. It allows the storage of medical information and record of each patient. It promotes faster retrieval of all necessary information. Current trends in healthcare, including robotic surgery, implementation of computers in patient tracking, and the mandates that surround electronic health record, has resulted in a need to examine the systems as part of the larger social-technical system (Stowers & Mouloua, 2018). The study of human technology facilitates the establishment of a user-friendly system customized according to the needs of a practice and facility.

The Key Areas of Your Workflow Design Diagram

The workflow design diagram below shows the correct process that the nurse in the scenario should have utilized to prevent errors.



Workflow Design Diagram











Review patient’s med box






Are Meds Available?

































Interaction between human and technology



Optional steps depending on circumstances



Key areas of the process



            Key areas of my workflow include scanning the patient ID, determining the need for further assessments, scanning the meds, administering, and documenting the drug administration. Scanning the patient ID is important as it provides essential information such as the name of the patient, previous conditions, any allergies, recommended medicine, and the dosage to be given. Scanning the availability of the med is also crucial. It is also important to determine the need for further assessment. This requires collaboration between the team members involved in patient care, including the physician. The need for assessment is determined by the progress of the patient. Other key areas include administering and documenting the administration of the drugs. This ensures that the medical records of the patient are up to date. The key areas ensure adherence to rights that include the right patient, drug, administration route, dose, time, indication for prescription, documentation, and right patient response (Hanson & Haddad, 2021). Key areas of documentation and scanning of the patient ID is an interaction point between technology and human needs. The system must be user-friendly, and humans should be accountable enough to execute their responsibility.

The focus of My Process

            The focus of the process is a combination of clinical staff, technology, and the patient. Each has a role to play in promoting safety. A major focus is, however, on the clinical staff and the technology. This is especially where technology and human being interact. Such points include scanning of the patient ID and documentation. Clinical staff must be accountable and follow the right procedures and processes at all stages of drug administration. Technology plays a critical role in making the relevant information readily available. The information must be accurate. Interaction between technology and human beings minimizes errors when characterized by user-friendly designs on the part of technology and accountability of the clinical staff.

Barriers or Challenges in Making any Workflow and System Changes

            One of the major challenges is skipping important steps. It is difficult to decide on the steps that are most important in the workflow. Leaving a step that may seem unimportant may result in a flaw in the workflow affecting the strength of the workflow, which may result in undesired outcomes. Another challenge is setting the steps in the proper order. There is a high likelihood of mixing priorities, and it may be hard to follow and understand the workflow resulting in misunderstanding. The workflow becomes less effective in achieving intended goals.

Methods to Address and Overcome the Barriers or Challenges

The barrier or challenge of skipping important steps can be overcome by mapping the previous workflow to ensure that all steps are involved and included. The previous or current workflow can be used as a draft in developing a new one. Outlining the steps in proper order can be achieved by outlining all the activities first and placing them in the proper order depending on how the activities are arranged.


The scenario is a good representation of how medication errors occur and common errors that occur in healthcare facilities. The errors can result from the system or human errors. Healthcare professionals, however, have a major role in preventing errors. Human-technology interaction is a key aspect in ensuring the safety of care. The workflow design diagram developed depicts crucial steps that should be taken by health professionals when administering drugs. Key areas include scanning patient ID, determining the need for assessment, and documenting drug administration. It was challenging to develop the workflow, particularly determining the steps involved in drug administration in their respective order. The challenge was, however, addressed by using previous workflows and outlining all activities involved in the process.



Ahmed, Z., Saada, M., Jones, A. M., & Al-Hamid, A. M. (2019). Medical Errors: Healthcare Professionals’ Perspective at A Tertiary Hospital in Kuwait. Plus One14(5), e0217023.

Hanson, A., & Haddad, L. M. (2021). Nursing Rights of Medication Administration. StatPearls [Internet].                                            

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical Error Reduction and Prevention. In-Stat Pearls [Internet]. Stat Pearls Publishing.

Stowers, K., & Mouloua, M. (2018). Human-Computer Interaction Trends in Healthcare: An Update. In Proceedings of the International Symposium on Human Factors and Ergonomics in Health Care (Vol. 7, No. 1, pp. 88-91). Sage CA: Los Angeles, CA: SAGE Publications.






                                    Appendix 1: Workflow Design Diagram















































Interaction between human and technology



Optional steps depending on circumstances



Key areas of the process

Get 20% off your first purchase