Posting on behalf of Stephanie O’Brien, PGY1 Resident:

Hello,

For my research project this year I identified a liquid medication dosing error in our neonatal intensive care unit that is not detected by our electronic health record. Physicians enter a mg/kg dose into the EHR which automatically calculates a mL dose based on the patient's weight and the drug concentration. The EHR does NOT alert the physician if the mL dose is unmeasurable so we are seeing several instances where patients are being prescribed unmeasurable doses.

For example, a patient may be prescribed 0.127 mL of a medication even though hash marks on a 1 mL dosing syringe only measure out to increments of 0.01. In this instance the EHR should round to 0.13 mL to make it measurable. I am hoping to receive feedback from peers who have electronic health records that are able to detect this error.

1. What Electronic Health Record do you use?
2. Is your EHR able to detect this measurement error?
3. Have you been successful in utilizing your EHR to correct this type of dosing error?
4. Any other insight, advice, or similar issues?

My goal is to work with our EHR (Sunrise Clinical Manager) to fix this issue, but would like to provide them with a recommendation on how this can be done or has been done with other systems. Any advice or support would be greatly appreciated.

Sincerely,
Stephanie O'Brien, PharmD
PGY1 Pharmacy Resident
St. Vincent Indianapolis