7/9/2021 12:00:00 AM
This alert addresses the potential medication errors that can occur when reliance on an electronic medication management system (order entry system) to calculate the correct volume (and dose) for a medication with multiple concentrations is not independently manually checked and verified. A case is described where the dose of HYDROmorphone calculated by the system would have resulted in a 5 fold overdose due to the system calculating the dose based on a difference concentration of the drug versus what was on hand. Recommendations to mitigate the risk of dosing calculations of drugs with multiple concentrations performed by electronic medication management systems are presented.
morphine oral solution,
narcotics/opiates, IV, transdermal, and oral
Safe use of medications with multiple concentrations in Electronic Medication Management (EMM) systems