Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.
Approach to Improving SafetySafety TargetResource TypeSetting of CareClinical AreaTarget AudienceError TypesOrigin/Sponsor
This study characterized dose errors on medication orders bypassing pharmacist review in a pediatric emergency department. Over 46,000 medication orders were placed in a 12-month period: of those, 32,000 bypassed pharmacist review through an auto verify function in the EHR. A small proportion (<1%) of these orders were deemed potentially erroneous; most were wrong doses (90%) and the rest were the wrong formulation or given to the wrong patient. None of the potential errors resulted in identifiable patient harm.