Description of Event or Problem · 0
JUST READ THE COMMUNITY NEWSLETTER WITH ALL THE FENTANYL PATCH ISSUES AND THOUGHT THIS COULD BE ANOTHER EXAMPLE OF WHERE THINGS GO WRONG. TECHNICAL AND MAYBE SPECIFIC TO OUR EHR BUT IT LAUNCHED A WHOLE EDUCATION SERVICE. EHR: (B)(6) REMOVE PATCH ORDERS: ONCE PATCH IS CHARTED ADMINISTERED, AN AUTOMATIC ORDER FOR " _DRUG_ PATCH REMOVAL" POPULATES IN THE MAR 72 HOURS AFTER ADMINISTRATION. IF YOU HOVER OVER THE ORDER IN THE MAR, YOU WILL SEE THE COMMENT THAT SAYS WHERE THE PATCH WAS ORIGINALLY PLACED. AT 1512: SCHEDULED START DATE FOR ORDER FENTANYL 25 MCG/HR EVERY 72 HRS AT 1812: FIRST PATCH ADMINISTERED TO RIGHT UPPER BACK [GIVEN 1 DAY LATE; ADMINISTRATION TIMES WERE NOT RESCHEDULED. THEREFORE, SUBSEQUENT DOSES WERE NOT RESCHEDULED FOR EVERY 72 HR DOSING FREQUENCY.] AT 1511: SECOND PATCH ADMINISTERED TO CHEST AT 1812: FIRST PATCH REMOVAL SCHEDULED, BUT IT WAS MISINTERPRETED AS A GLITCH THAT IT WAS TOO EARLY TO REMOVE PATCH. IT WAS IGNORED AND NOT NOTICED UNTIL LATER ON IN THE DAY. PATIENT HAD BOTH PATCHES FOR APPROX 1 DAY. NO CLINICAL EFFECTS AS A RESULT. (B)(6). SUBMISSION ID: (B)(4).