Management of Change: What model to use?

The Straits Times 07Feb2021: 5 doses of Covid-19 vaccine given to S'pore National Eye Centre worker due to human error

It was reported that a staff member at the Singapore National Eye Centre (SNEC) has been mistakenly given the equivalent of five doses of the Pfizer-BioNTech Covid-19 vaccine. This occurred during a vaccination exercise on Jan 14, and was due to human error resulting from a lapse in communication among members of the vaccination team, said SNEC on Saturday (Feb 6).  It said it has been following up closely with the staff member, who remains well.

SNEC said the worker in charge of diluting the vaccine had been called away to attend to other matters before it was done.

A second staff member had then mistaken the undiluted dose in the vial to be ready for administering. The error was discovered within minutes after the vaccination.

As a safety measure, the vaccination exercise at SNEC was stopped immediately upon detection of the error, and the rest of the staff were vaccinated at SGH.

The centre is not involved in the vaccination of other groups.

The SNEC has apologised to the affected staff member and the worker’s family, said Professor Wong Tien Yin, the medical director of the centre. “SNEC takes a very serious view of this incident. The safety of those receiving the vaccination during our staff vaccination exercise is of our utmost priority,” he added.

He said that the centre has done a thorough review of its internal processes, and taken steps to tighten them so that such lapses do not occur again.

This isn’t the first time blunders made by public hospitals and health institutions like this have been reported. Many, I believe went un-reported.

This event is just another example to illustrate the importance of managing change in the workplaces and organizations. Deploying an reactive approach towards managing change could be fatal at times. Some may question: shouldn’t ‘a thorough review of internal processes’ be conducted prior to the implementation of change? The short answer is probably YES! Again, this depends on the competencies and skills of the change management team and the change approach or model deployed in this hospital.

There are many change management models designed by many authors. Some models are relatively complex to understand without an in-depth knowledge of its benefits, pitfalls and implementation difficulties. The simplest change management model is the 5M Approach (copyrighted) as depicted here. This change management model can be used to suit every situation and in various change categories: financial, operations, quality, environmental, workplace safety and health aspect.

For more information and training on the use of this change management model, kindly contact us.