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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?

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