Page 9 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

Medication Safety in EHR

• Verify accuracy of allergies at each encounter or make a
notation of no allergies.

• If using dropdown boxes from which to select medications
and/or dosages, use care to verify that the correct

medication and correct dose have been selected before

“entering” the information into the e-Prescribing system.

» Ideally, the ordering provider should enter the

original medication order in the EHR. However, if
your practice allows licensed professionals to assist

the providers by entering medication orders, great
caution must be exercised when using dropdown

boxes in order to avoid selecting an incorrect
medication or dosage, and the source of the

authorization for the medication order should always
be documented.

If an EHR alert/alarm is triggered due to a contraindication or
potential drug interaction with other medications, note this alert

in the record and document how it was addressed or why it was
overridden. If the problem triggered is a dosing problem (i.e.,

high dose, wrong route) check the dose and name of drug to
verify correct medication was selected from dropdown menu,

and if correct, note the alert in the record and document how it
was addressed, or again, why it was overridden. Notification that

the quantity of medication prescribed or the duration for which
it has been prescribed exceeds that which is recommended by

the manufacturer should prompt a recheck of the quantity and
duration ordered to verify these were selected accurately from

dropdown menu, and if there is a good medical justification
to exceed the recommended dose or duration, the physician

should document appropriately.

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