Approved Hospital Formulary
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Approved Hospital Formulary
04/15/20 md Refresh Order Profile alert
April 15, 2020
What can happen if you are verifying orders at the same time a provider is entering/discontinuing orders on the same patient in PowerChart?
Yesterday, a near miss was reported where a patient's (post-stent) prasugrel was almost omitted due to this exact situation...
* The physician entered a duplicate order for prasugrel (previous order entered by NP 1 hour earlier)
* Simultaneously, the pharmacist and the physician recognized the duplicate orders
* The physician discontinued the previous order entered by the NP
* The pharmacist discontinued the new unverified order entered by the MD
* Fortunately, the nurse noticed that the post-stent patient was missing his prasugrel order and contacted the MD
This is a sticky situation and could happen at any time -
There is an alert that appears in certain situations (but not all) where another user is modifying the profile while you are verifying orders for the patient.
Please review the attached flyer that provides some recommendations to prevent errors; this will be discussed in huddles as well
Let me know if you have questions and thanks for all you do!