DISPENSER, SOLID MEDICATION

Description of Event or Problem

CHARACTER REQUIREMENT ¿ ISMP RECOMMENDS 5 CHARACTERS TO BE ENTERED BEFORE POPULATING A LIST IN ADCS. I¿M REPORTING THAT EPIC AND OTHER EMRS DO NOT MEET THE REQUIREMENT, RESULTING IN THE SAME ROOT-CAUSE ERRORS. DISAPPOINTINGLY, EPIC IS AWARE OF ERRORS AND HAS NO PLAN TO ALLOW ORGANIZATIONS TO DECREASE THIS RISK VIA LOCAL CONFIGURATION SETTINGS. TODAY, EPIC REQUIRES ONLY 1 CHARACTER. TWO RECENT ERRORS THAT REACHED PATIENTS. FOSAPREPITANT WAS ACCIDENTLY ORDERED AND ADMINISTERED TO A PATIENT INSTEAD OF FOSPHENYTOIN (INPATIENT). SECOND ERROR INVOLVED AN ORDER FOR METRONIDAZOLE INSTEAD OF METFORMIN (OUTPATIENT). BOTH OF THESE ERRORS COULD EASILY BE PREVENTED BY REQUIRING ADDITIONAL CHARACTERS. I WOULD ARGUE THAT THE RISK AT ORDERING IS MUCH GREATER THAN THE RISK AT ADC, AS THE LIST IS MUCH GREATER AND NOT MERELY LIMITED TO WHAT IS STOCKED ON THE CABINET. I¿VE DISCUSSED THIS SEVERAL TIMES IN THE PAST WITH EPIC. THEIR MOST RECENT RESPONSE INCLUDED SOME HEAD-SCRATCHING LOGIC: ¿THE MAIN REASON THAT WE HAVEN¿T MADE THIS CHANGE IS THAT 20% OF SEARCHES FOR MEDS ARE EITHER 3 OR 4 CHARACTERS. THINGS LIKE ZOF, ZOFR, KCL, TMUS, IBU, IBUP¿ THIS IS PRECISELY THE REASON WE NEED IT! ¿FUZZY MATCHING FOR ORDER SEARCH RESULTS WAS INTRODUCED IN EPIC 2018, ALLOWING SEARCHES WITH NO EXACT MATCHES TO SHOW OTHER ORDERS WHERE THE NAME, DISPLAY NAME, OR A SYNONYM MATCHES THE CLINICIAN¿S SEARCH TERM PLUS ONE OR TWO MISTAKES¿ EVEN THOUGH I HAVE NO ISSUE WITH FUZZY MATCHING PER SE, IT CREATES ANOTHER OPPORTUNITY TO GET THINGS WRONG BY QUICKLY ENTERING A FEW KEYSTROKES. SO, NOT ONLY DO WE HAVE NO CHARACTER LIMIT WE ALSO HAVE NO NEED TO TYPE THE *CORRECT* CHARACTERS! ERROR REACHED PATIENT, NO PATIENT HARM. (B)(6). PHONE: (B)(6). EMAIL: (B)(6). SUBMISSION ID (B)(4).