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PSNet: Patient Safety Network
Journal Article

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

Todd SE, Thompson AJ, Russell WS. Pediatr Emerg Care. 2020:Epub Jan 21.

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.