Description of Event or Problem · 1
THE CPOE SYSTEM, EPIC, IS ONE OF THE LARGEST IN THE UNITED STATES. EPIC HAS AN INHERENT PROBLEM: ORDERS FOR MEDICATION SHOW UP IN THE MEDICATION ADMINISTRATION CHARTING (MAR) SECTION IN AN ERRONEOUS, AND, I BELIEVE, CONFUSING AND POSSIBLE DANGEROUS MANNER. THE MAR, AND THE LABEL THAT ISSUES FROM THE PRINTER IN EPIC, CONFUSES PRODUCT STRENGTH WITH DOSE. FOR EXAMPLE, A 3 MG DAILY DOSE OF SIROLIMUS APPEARS AS "SIROLIMUS TABLET 3 MG; DOSE 3 MG ORAL DAILY. SIROLIMUS IS NOT MARKETED IN A 3 MG TABLET. SIMILARLY, ANY DOSE OF A PRODUCT THAT DOES NOT EXACTLY MATCH THE TABLET STRENGTH APPEARS IN THE SAME CONFUSING PATTERN: E.G., A DOSE OF MESALAMINE CAPSULES 1600 MG APPEARS AS "MESALAMINE CAPSULE 1600 MG DOSE 1600 MG ETC." MESALAMINE IS NOT MARKETED AS A 1600 MG CAPSULE. THE ABOVE SHOULD READ, CORRECTLY, IN THE MAR (AND ON LABELS) AS: SIROLIMUS TABLET (OR TABLETS) 1 MG, DOSE 3 MG, AND MESALAMINE CAPSULE (OR CAPSULES) 400 MG, DOSE 1600 MG, ETC. THIS INHERENT SOFTWARE ERROR HAS WIDESPREAD DISTRIBUTION, I BELIEVE, AND SHOULD BE RECTIFIED. MY ATTEMPTS TO POINT OUT THIS PROBLEM HAVE BEEN IGNORED LOCALLY. SEVERITY: CIRCUMSTANCES OR EVENTS HAVE CAPACITY TO CAUSE ERROR. (B)(6).