Description of Event or Problem · 1
THIS INCIDENT TYPIFIES INNUMERABLE SIMILAR INCIDENTS WHEREBY A MEDICATION THAT IS ORDERED DAILY AT TWO DISTINCT DOSES TO BE ADMINISTERED DAILY AT TWO DISTINCT TIMES IS INVARIABLY INCORRECTLY SCHEDULED BY THE MILLENNIUM CPOE DEVICE. THE DEVICE SCHEDULES BOTH DOSES TO BE ADMINISTERED AT THE SAME TIME, THE EARLIEST TIME. THIS CAUSES AN EXCESSIVE DOSE OF MEDICATION TO BE ADMINISTERED AT ONCE, OR ALTERNATIVELY, CAUSING THE SECOND DOSE OF MEDICATION TO BE SKIPPED BY THE NURSE AND DISCARDED AS BEING DUPLICATE. FOR INSTANCE, VENLAFAXINE WAS ORDERED AS 150 MG DAILY AT 9AM AND 75 MG DAILY AT 2PM. THE NURSE TASK LIST SHOWED 225MG TO BE ADMINISTERED AT 9AM. THE E-MAR DISPLAYED THE CORRECT DESCRIPTION IN THE MEDICATION COLUMN, BUT IT WAS NOT SCHEDULED AT THE CORRECT TIME ON THE TIME LINE. THIS DEFECT AND INTERNAL INCONSISTENCY ENDANGERS ALL PTS WHO ARE TO RECEIVE MEDICATIONS OF TWO DISTINCT DOSES AT TWO DISTINCT TIMES.