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Publication Type: Safety Information
Single or Multiple Incident: Multiple
Date: 7/9/2021 12:00:00 AM
Country: Australia
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.

Additional Details

Medication/Gas/Fluid:
opioids, HYDROmorphone injection, morphine injection, morphine oral solution, oxycodone injection, digoxin injection, furosemide injectin, ketorlac injection
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral

Rules / Policies / Procedures
  1. Administering clinicians are reminded to independently calculate the required volume of medication considering the prescription and what is available in the clinical area.
  2. Second person checks should be undertaken for all relevant medication orders as out of lined in the Medication Handling in NSW Public Health Facilities Policy Directive. The independent second check includes (but is not limited to): confirming selection of the correct medication, that the dose is appropriate, and the calculations are correct.
  3. In consultation with your local Drug and Therapeutics Committee, consider appropriateness of mitigation strategies currently in place to prevent any potential errors involving medications available in multiple concentrations occurring. Attention should be given when new concentrations are introduced.

Safe use of medications with multiple concentrations in Electronic Medication Management (EMM) systems