[47294435]
We have some protocols for critical care drips that involve fractions, e. G. , (if xyz holds drip for 30 minutes and resume at x/x previous rate). We use (b)(6) as our hospital emr. (b)(4), which we write our protocols and policies in, will autoconvert x/x (among others) into the proper fraction font. When we cut and paste that protocol into an order set build, (b)(4) will show that fraction font. However, when the order set protocol is viewed by the nurse on the emar, the fraction font is simply omitted, resulting in a medication error. (b)(4) has worked with us on this, and determined that various pieces of their system may or may not show those fraction fonts (or any ascii extended character) and their guidance is to instruct users to simply never copy and paste, as it may be a long involved rebuild of many pieces of their software to prevent this bug from occurring. While we see that (b)(4) says to use these fraction fonts, they also say to follow it by (fraction-in-words) as a safety measure, which we are now implementing. However, the issue still remains, some places in the system show different text than other places in the system because of the inconsistent way ascii extended characters are handled in (b)(4). Medication not administered to or used by the patient: no. Relevant materials not provided: none, severity: circumstances or events have capacity to cause error. (b)(4).
Patient Sequence No: 1, Text Type: D, B5