INSTITUTE FOR SAFE MEDICATION PRACTICE RECOMMENDS AUTOMATED DOSE-LIMIT WARNINGS FOR PHARMACY
ISMP newsletter stresses the importance of setting and heeding automated warnings.

Responding to recent news reports of patient injuries due to overdose and med errors, the ISMP has published a safe practice recommendation for pharmacies using computerized order entry and automated compounders. The newsletter recommends that all facilities install and maximize automated dose-limit warnings in their pharmacy computer system and automated compounders. The recommendation continues,

“Consider printing all alerts encountered during the order entry process so the person checking the order entry can also view and respond to the alerts. Reinforce with all staff the importance of reading and reacting to warning screens.”

Baxa, with the Exacta-Mix™ and MiroMacro™ automated compounders, allows users to add hard stops and soft warnings in its Abacus™ Order Entry and Calculation Software if a dose limit is breached when entering an order. More recently, we have added ‘catastrophic’ limits in the program to stop the compounding process completely to prevent massive 100-fold or 1,000-fold overdoses caused by decimal point errors or mcg to mg conversion errors. These warnings, when properly enabled and acknowledged, combine with the professional judgment of the pharmacist to provide the safest solution for compounding multi-ingredient IV solutions.

For more information on Baxa hardware and software for automated compounding, contact Customer Service at 800-567-2292 or return the enclosed Business Reply Card.