Reducing Errors where Concentration is interpreted as Dose

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jrufo@ismp.org. 

1 post / 0 new
Log in or register to post comments
Thu, 01/02/2020 - 12:45
#1
Jennifer Marie ...
Jennifer Marie Soto Meyer's picture
Offline
Last seen: 1 month 6 days ago
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!

Top