[5093050]
Does range checking in the ehr system does not follow clinical logic. When entering an iv order utilizing multiple vials of the same medication to accommodate dosing and minimize waste such is common practice in oncology pharmacy, the dose range checking system does not function with the logic a clinician would expect. For example, when an order is entered (or verified by the pharmacist) that would contain two different vials sizes, the system does not check the dose based on the total dose to be administered. Rather, the system looks to each individual vial. This could lead to an over dose if the individual via sizes where within the dosing limit but the combined vial sizes or actual doses was above the dosing limit. This error could occur with commonly used oncology medications such as bevacizumab (avastin) gemcitabine (gemzar) ixabepilone (ixempra) bendamustine (treanda) test your system under all circumstances to make sure you understand how it functions and more importantly what are it's limitations. Submit enhancements to vendors to make them aware of the potential for error. Reporter's recommendations: test your system under all circumstances to make sure you understand how it functions and more importantly what are it's limitations. Submit enhancements to the vendors to make them aware of the potential for error. Relevant materials provided: none. (b)(4).
Patient Sequence No: 1, Text Type: D, B5