National Survey of Safety Features with Pharmacy Computer Systems

Please complete this survey to test the effectiveness of important safety features with your pharmacy computer system. Submit your findings to ISMP here (or by fax at 215-914-1492 if without Internet access) by June 15, 2005. Your individual results, as well as the published aggregate results, will be useful when planning computer system enhancements in the future.

A. Create a test patient** in the medication order entry system used by pharmacists. Then, enter each of the medication orders below into your computer system. Be sure to include any specific patient parameters necessary in the test patient profile before entering each order. Then record on the chart whether your computer system provided a warning about each unsafe order, whether staff were able to override the warning (if it appeared), and if the override required documentation of a reason.
**IMPORTANT NOTE: Please test the above unsafe orders in a TEST patient profile ONLY, not an active patient profile. Ensure that the test patient profile created for the survey is appropriately interfaced so the capabilities are exactly the same as with an active patient profile.

Medication Orders
Each order represents a hazard alert or an adverse event published in the ISMP Medication Safety Alert!, and most have led to (or could cause) serious patient harm, sometimes death.
Test Patient Parameters
(if applicable)
Unsafe Order Detected
Able to Override Warning
Able to Override Warning if Reason Noted
1. methotrexate 7.5 mg PO daily Rheumatoid arthritis
2. Wellbutrin XL 300 mg PO daily Seizure disorder
3. Percocet (any strength) PO q4h prn Also: Tylenol 650 mg PO q4h prn
4. Fluzone 0.5 mL IM Allergy to eggs
5. Zyban 150 mg PO BID Also: Wellbutrin SR 150 mg PO BID
6. Lovenox 60 mg subcutaneously q12h Also: heparin 1,000 units/hour IV
7. Sporanox 100 mg PO daily Congestive heart failure
8. St. John's Wort 300 mg PO TID indinavir 800 mg PO q8h
9. Varivax 0.5 mL subcutaneously Female; pregnant
10. metformin 500 mg PO BID Serum creatinine: 2.1 mg/dL
11. Neutra-Phos-K 2 packets PO TID Potassium: 6.1 mEq/L
12. rifampin 600 mg PO daily Also: saquinavir 1,200 mg PO TID
13. lomustine 190 mg PO daily for 6 weeks Body surface area: 1.46 m2
14. carbamazepine 400 mg PO BID 4-year-old child
15. carbamazepine 1,300 mg PO BID No specific parameters
16. Lantus 25 units IV now Diabetes
17. vincristine 2 mg intrathecally today Acute leukemia
18. amphotericin B 260 mg IV daily No specific parameters
B. Please evaluate the following statements about your CURRENT pharmacy computer system's capabilities and answer Yes or No.
1. Alerts that have little or no clinical significance routinely appear on the screen.
2. Alerts that have little or no clinical significance can be eliminated easily.
3. The system allows you to build alerts for serious error-prone situations (e.g., look-alike names, special precautions).
4. The system allows you to use tall-man letters to differentiate between look-alike drug name pairs (hydrOXYzine, hydrALAzine).
5. The system allows you to change font and color to highlight look-alike drug name pairs to prevent confusion.
6. The system produces computer-generated medication administration records (MARs), which are used in the hospital.
If yes, nurses generally feel the computer-generated MARs are safer than handwritten MARs.
7. The system is directly interfaced with the laboratory system.
If yes, the system automatically screens orders and alerts staff according to current laboratory values.
8. The system allows for direct prescriber order entry AND prescribers directly enter at least 75% of all medication orders.
9. The system is capable of providing reports of drug warning overrides by staff.
10.The system is integrated with a point-of-care bar-coding system used on patient care units during drug administration.
C. Drug information updates from your vendor are received:
D. If the FDA publicizes an important new drug interaction today, how long would it be before the new information is actually loaded into your pharmacy computer system and interactive?
E. How long have you been using your current pharmacy computer system application?
F. Please choose the type of healthcare provider that best describes your organization.


Copyright © 2018, ISMP. All rights reserved