Description of Event or Problem · 1
WE HAVE AN EXTENSIVE LIST OF THERAPEUTIC SUBSTITUTIONS APPROVED BY OUR P&T COMMITTEE THAT PHARMACISTS ARE ABLE TO ACT ON. IN A RECENT INCIDENT, A PHARMACIST WAS MAKING A THERAPEUTIC SUBSTITUTION FROM SOLIFENACIN 10 MG QDAY TO OXYBUTYNIN XL 10 MG QDAY. SINCE IT WAS A SUBSTITUTION, THE PHARMACIST HAD TO MANUAL ENTER IT INTO THE SYSTEM. WHEN DOING SO THEY USED THE EHR'S QUICK KEY FUNCTIONALITY WHICH BY DEFAULT TAKES THE FIRST THREE LETTERS OF THE GENERIC AND STRENGTH OF THE DRUG. IN THIS CASE THAT WAS OXY10. SINCE THERE ARE MANY INSTANCES OF MEDICATIONS THAT FIT THAT QUICK KEY THAT COMES UP AS PRODUCTS ARE OXYBUTYNIN XL 10 MG, OXYCODONE SR 10 MG, AND OXYTOCIN 10 UNITS/ML. INADVERTENTLY THE PHARMACIST CHOSE THE OXYCODONE SR 10 MG. LUCKILY THE NURSE NOTICED THE THERAPEUTIC INTERCHANGED DIDN'T MAKE SENSE AND CALLED THE PHARMACIST TO CLARIFY. WE ARE NOW WORKING ON BUILDING THESE THERAPEUTIC SUBSTITUTIONS INTO OUR SYSTEM, SO THEY OCCUR AUTOMATICALLY. THIS WILL ASSURE THE PHARMACIST WON'T HAVE TO MANUALLY ENTER THESE AND ELIMINATE THE POSSIBILITY OF MAKING THIS ERROR. HOWEVER, FROM A LARGER SYSTEM PERSPECTIVE THE POSSIBILITY STILL EXISTS IF ENTERING VIA TELEPHONE OR VERBAL FOR EMERGENCY SITUATIONS. THE QUICK KEYS ARE HARDCODED BY THE HER AND NOT ABLE TO BE CHANGED TO MY KNOWLEDGE. (B)(6); ACCESS NUMBER: (B)(4).