Question

• In our CPOE system, a medication order was generated for warfarin 7 mg daily. Using an HL7 interface message, the medication order was communicated to an external pharmacy system. Because there was no dispensable product of warafin 7 mg, the pharmacist converted the order into dispensable products, a 5-mg tablet and a 2-mg tablet. Several days later, clinicians observed that the patient’s anticoagulation laboratory results (INR) were at panic levels, but there had been no easily identified originating event. The anticoagulation medications were reviewed and the clinicians were surprised at the warfarin dosing–it was much higher than originally ordered. The clinicians ordered a dose of warfarin 7 mg daily, yet the order and the eMAR both indicated a dose of warfarin 14 mg. Upon review of the audit trail, the provider entered warfarin 7 mg, but after the pharmacy verification, the order was modified to warfarin 14 mg. The first step was to implement an immediate workaround, which was to discontinue the order and reenter the medication order differently. Because the medication dose required two separate products to be dispensed (warfarin 2 mg and 5 mg), the order was reentered successfully as two separate medication orders.

Read the following case study. Then in a minimum of 200 words answer the following questions. Responses should be logical and substantial.

• What are some lessons learned?
• What could have been done to prevent this from happening?

Answer 1

The main lesson learned here is the medication error by the pharmacist by modifying the providers order.The ORMs has been modified as the ordered medication dosage of 7mg was not dispensable, so the pharmacist modified it to 5mg and 2mg dispensable tablet and got a dose of finally 14 mg and issued the patient. This scenario specifies the need of counter checking the orders before supplying to the patient,if a pharmacist has any query it has to be immediately clarified. Warfarin is a drug which can be fatal even when given in little excess than the prescribed dose to the patient.In simple the electronic Medication Administration Record has a error which has to be corrected first. This is a manual based technical error in medication administration

This can be prevented in the following way

• Double checking the order of the prescription before issuing
• Informing the concerned provider in regards to the availability of the dosage of dispensable medications ( that 7mg tablet are not available instead in order to get a dose of this 5mg and 2mg can be dispersed to the patient)
• Educate and train the pharmacist and the other healthcare professionals in regards to the use of HL7 technology in transferring data between organizations.