[60349233]
Pt was discharged from our children's hospital with a prescription for acetaminophen 60 mg. The product selected was 160mg/5ml and showed a dose of 60mg or 1. 88 ml which is what the pt was receiving in house. We use (b)(4) at our facility. The discharge medication reconciliation was done through (b)(4) as is our process, but the dose of the drug does not transmit to the pt summary that is provided to the pt. Only the product and frequency transmit. The dose does transmit to any prescriptions but since this was an over the counter medication, the parents were using the pt summary to know what to give their child. It appeared on the pt summary that the pt should receive acetaminophen 160mg/5ml as their dose. The parents gave the pt this much higher dose of acetaminophen after discharge and the pt was then readmitted to the emergency department with signs and symptoms of tylenol toxicity and received acetylcysteine for treatment of overdose. This error was presented at our facility safety operations council and our info systems department escalated this concern to (b)(4) to address since this potentially impacts all users of (b)(4) who prescribe over the counter products upon discharge. We have not received a response from them regarding a resolution for this issue. (b)(4). Severity: error resulted in treatment or intervention; temporary pt harm.
Patient Sequence No: 1, Text Type: D, B5