Reducing Errors where Concentration is interpreted as Dose

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Thu, 01/02/2020 - 12:45
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Jennifer Marie ...
Jennifer Marie Soto Meyer's picture
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Joined: 01/11/2018 - 11:49
Reducing Errors where Concentration is interpreted as Dose

Happy New Year everyone! Curious if anyone has made changes in the EHR across the board (all drugs or a specific subset of drugs) to reduce the likelihood the nurse accidentally interprets the product concentration as the dose to administer. Would love to understand what changes people have made.

I recall ISMP commenting on this risk in the "2016 risks that might otherwise fall of the radar". One of the modifications we are considering includes completely removing the concentration information from the "primary" MAR line in our EHR for injectables and/or oral liquids. Of course we are considering implications to labels, ADC, etc.

Would love to hear any thoughts or lessons learned from others!

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