ISMP
ISMP
Home Support ISMP Newsletters Webinars Report Errors Educational Store Consulting FAQ Tools About Us Contact Us
ISMP
ISMP
ISMP Facebook

Mmmm...check out this problem order


From the Oct. 22,1997 Issue

PROBLEM: An order for one angiotensin converting enzyme inhibitor was converted into another with the stroke of a pen. The order on the third line of the graphic below is actually for Accupril® (quinapril), but it looks more like Monopril ® (fosinopril). A unit clerk used an "M" to check off each drug order as a way of denoting that it was transcribed to the medication administration record (MAR). It may have been clear on the original order, but when pharmacy reviewed the noncarbon order copy, they saw "Monopril."

SAFE PRACTICE RECOMMENDATION: Depending on their form and position, using check marks or other check-off symbols when processing lengthy medical order sets can prove hazardous. For example, an order for "40 mg Tylenol“ (acetaminophen) drops" for a baby can become 140 mg if the check mark preceding the dose looks more like a "1." Also, listing orders by number is a problem; 1. 2 million units of penicillin looks like 1.2 million even though the prescriber intends order # 1 to be 2 million units of penicillin. Safety tips: avoid using check marks, especially on an original order form that provides an NCR copy to the pharmacy. If check marks are used on any form, be careful to use them in a way that will not interfere with interpretation. Always list the drug's dose after its name, and do not number medication orders. We long for prescriber computer order entry, don't you?

Resources
Acute Care Main Page
Current Issue
Past Issues
Highlighted articles
Action Agendas - Free CEs
Special Error Alerts
Subscribe
Newsletter Editions
Acute Care
Community/Ambulatory
Nursing
Long Term Care
Consumer
Home | Contact UsEmployment  | Legal Notices | Privacy Policy | Help Support ISMP
Med-ERRS Med-ERRS | MSOMedication Safety Officers Society | Consumer Medication SafetyFor consumers
 ISMP Canada ISMP Canada | ISMP Spain ISMP Spain | ISMP Brasil ISMP Brasil | International Group | Pennsylvania Patient Safety Authority

200 Lakeside Drive, Suite 200, Horsham, PA 19044, Phone: (215) 947-7797,  Fax: (215) 914-1492
© 2017 Institute for Safe Medication Practices. All rights reserved

 
ISMP
ISMP