[MEDITECH-L] Rate of "UD" for IV orders in Meditech

[Roger Beverly]

The most recent version of the ISMP Medication Safety Alert describes a
med error involving a Cardizem drip being infused over an hour due to a
rate of "UD" on the order. Apparently, this was misinterpreted by the
nurse as 'unit dose' instead of 'as directed'. The recommendation from
ISMP is not to use UD for a rate. This creates a problem in Meditech
because the only choice for an as directed rate is UD. Individual
hospitals can not add or change the IV rate keywords, nor is Meditech
changing them per our conversation yesterday.

Here is the solution we have used. Within the NPR label program that is
attached to our IV order types, I have replaced 'rate' with a computed
field that prints "As Directed" instead of "UD".

VAL=IF{@PHA.PARAM.keyword.iv.rate.name[@rate];

VAL=@rate,"("_@duration_")"}

Hope that helps you out.

Roger

Roger Beverly, PharmD

Conway Medical Center

300 Singleton Ridge Rd

Conway, SC 29526

rbev...@cmc-sc.com

"UD"-an ambiguous and

dangerous abbreviation. A

serious medication error resulted when a nurse did

not know what "UD" meant after a pharmacist

added it to directions on the electronic medication

administration record (eMAR). The rate of infusion

for an IV diltiazem solution was not yet known in

the pharmacy, so the pharmacist who entered the

prescription into the computer entered "UD" (ut

dictum or "as directed") from a drop-down list

used to populate the rate field. The nurse, upon

seeing the notation on the eMAR, thought it meant

that the 125 mg infusion was a "unit dose"

injection. The nurse proceeded to give

the diltiazem at 125 mg/hour and

infused the entire dose over 1 hour

(the rate should have been 5

mg/hour). The nurse then requested

and received another diltiazem drip

from the pharmacy and administered

the entire 125 mg infusion again over

1 hour. Pharmacy staff did not

question why another bag was

needed so soon. The patient later

expired.

====================================

Please do NOT send messages that ask "Please post to the list" These are useless messages that just waste the email server's resources. Instead, email the original requester and ask that they send you or post the results of their question.

To UNSUBSCRIBE, go to http://MTUSers.net
for information.

The meditech-l archives (and other tips) can be found at
http://mtusers.net/zarchives

Job opportunities in the Meditech community can be found at
http://mtusers.net/zjobs

[Roger Beverly]

The most recent version of the ISMP Medication Safety Alert describes a med error involving a Cardizem drip being infused over an hour due to a rate of "UD" on the order.  Apparently, this was misinterpreted by the nurse as 'unit dose' instead of 'as directed'.  The recommendation from ISMP is not to use UD for a rate.  This creates a problem in Meditech because the only choice for an as directed rate is UD.  Individual hospitals can not add or change the IV rate keywords, nor is Meditech changing them per our conversation yesterday. 

Here is the solution we have used.  Within the NPR label program that is attached to our IV order types, I have replaced 'rate' with a computed field that prints "As Directed" instead of "UD".

VAL=IF{@PHA.PARAM.keyword.iv.rate.name[@rate];
VAL=@rate,"("_@duration_")"}

Hope that helps you out.

Roger

Roger Beverly, PharmD
Conway Medical Center
300 Singleton Ridge Rd
Conway, SC 29526
rbev...@cmc-sc.com

>From the ISMP Alert: