Description of Event or Problem · 1
CERNER MILLENNIUM COMPUTER SYSTEM - VERSION 2007.9 - USED HERE AT OUR ORGANIZATION FOR PHYSICIAN MEDICATION ORDERS -CPOE-, NURSING DOCUMENTATION, AND PHARMACY PRESCRIPTION PROCESSING HAS SIGNIFICANT DEFICIENCIES RELATED TO DISPLAYING SMALLER VOLUME VALUES. THE DEFICIENCY IS FELT BY OUR ORGANIZATION TO BE A PT SAFETY CONCERN, WHICH IS WHY THE REPORT IS BEING GENERATED. THE PT SAFETY ISSUES ARE DETAILED BELOW. ISSUE #1, WHEN THE DISPENSED VOLUMES ARE ASSIGNED BY THE SYSTEM, THE VOLUMES ARE ROUNDED TO 0.01 MLS. THIS IS PROBLEMATIC WHEN NEW SYRINGES ON THE MARKET ARE CAPABLE OF DRAWING DOSES IN 0.005 ML INCREMENTS. THEREFORE, A DOSE OF DESMOPRESSIN THAT WAS SUPPOSED TO BE 0.025 ML = 0.1 MCG IS ROUNDED TO 0.03 ML= 0.12 MCG, WHICH REPRESENTS A 20% ERROR IN THE DOSE. THIS ISSUE IS HARD CODED AND NOT A PREFERENCE THAT WE CAN CONTROL. THIS PROBLEM HAS BEEN RAISED WITH VARIOUS INDIVIDUALS AT CERNER WITHOUT ANY RESOLUTION. THIS PROBLEM HAS ALSO BEEN RAISED BY AT LEAST 2 OTHER CHILDREN'S HOSPITALS; THEREFORE, OUR HOSPITAL IS NOT ALONE DEALING WITH THIS ISSUE. ISSUE #2, WHEN THE VOLUME IS LESS THAN 0.01 ML, THE VOLUME DOES NOT DISPLAY WITH THE ORDER -NOTE: NORMALLY IT DOES-. BEFORE PHARMACY VERIFICATION, THE ORDER READS AS FOLLOWS "XX MG/N/A ML". THIS IS ANOTHER SAFETY CONCERN BECAUSE THE NURSE TRYING TO ADMINISTER THE DOSE WILL HAVE TO CALCULATE THE VOLUME TO BE ADMINISTERED. RELATED TO THIS, WE ALMOST HAD A 10 FOLD INSULIN ERROR RELATED TO THIS SPECIFIC DEFECT. SECONDLY, WHEN THE PHARMACIST TRIES TO VERIFY THE ORDER, THE ORDER FAILS IN THE PROCESSING. THIS ISSUE HAS ALSO BEEN RAISED WITH THE CERNER CORP WITHOUT A RESOLUTION.