If your EMR lets you set default drug doses, pre-programmed drug, dose, route and timing details could put patient safety at risk and lead to wrong-time and wrong-dose errors. That's the conclusion reached by an analyst for the Pennsylvania Patient Safety Authority, who reported her findings in the September issue of the Pennsylvania Patient Safety Advisory.

Through a database search, she found 324 default-value-related incidents had been reported to the authority, including 200 wrong-time errors, 71 wrong-dose errors and 28 inappropriate automated stop orders. Of those events, 128 were caused by a user's failure to change a default value, 19 when the software overwrote user-entered information and 16 when the software entered default details after a user failed to complete a form.

The analyst urges facilities to take note of how their users view and enter time data, to periodically review and update outdated values and to make sure users can easily distinguish between user-entered and system-default data.

David Bernard