[5093493]
Delay in administration of a pre-operative antibiotic due to disparate information within the ehr. A physician entered an order for cefazolin 2 gram to be administered pre-operatively. The pharmacist correctly adjusted the administration time to coincide with facility standards. Unfortunately, the ehr displays the order status differently in the operating room system (where operating room nurses record drug administration) verses the electronic medication administration record (emar). In certain instances, the system will show the status of a "one time" order as discontinued 1 minute after it was placed. The emar will maintain a status of active until it is administered when it will immediately show as discontinued. Conversely, the operating room system follows the system convention and displays the medication as discontinued 1 minute after it is ordered, even though it has not been administered. The operating room nurse, have seen the cerfazolin order with a status of "discontinued", did not administer the cefazolin which led to a delay in care. Vendors should be expected to display order status consistently across their software modules. The ehr used in this case is considered a fully integrated ehr platform yet it does not function in that fashion. Where did the error occur: hospital. Hospital unit: operating room. Type of staff made initial error: nurse. Pt counseling provided: unk. (b)(4).
Patient Sequence No: 1, Text Type: D, B5