• E-mail
• Print
• RSS

Avoid these two CPOE errors at your hospital

Pharmacy Regulation Resource, January 26, 2005

Check out these examples from the U.S. Pharmacopeia MEDMARX medication error reporting database of the types of errors can occur with computerized physician order entry (CPOE).

Wrong patient: A physician entering an order for piroxicam accidentally selected the wrong patient on the order-entry screen. The prescriber mistook the patient for a family member with the same last name.

The family members recognized the error before they took any medication and brought the error to the physician's attention.

Inexperienced staff: A traveling physician working temporarily at a hospital was in the neonatal intensive care unit (NICU). He entered orders for fentanyl and midazolam drips into a predetermined order set in the CPOE system.

The order he placed would have resulted in a 500 mL infusion bag with two additives. Typically, staff would have used small-volume infusion syringes of 10 mL to 20 mL. Also, the predetermined order set incorrectly computed the total amount of drug per 500 mL, which means the patient would not have received the correct hourly dose.

A pharmacist's review of the order uncovered the error. Staff later concluded that the order set was available hospital-wide and that NICU physicians had not previously used the predetermined order set.

• E-mail to a Colleague
• Print
• RSS
• Archive