FHIR005

Receiving systems automatically processes medication information

Hazard Description

Prescription is incorrect and not as the Prescriber intended.

Potential Clinical Impact

Incorrect medication dispensed to patient which can lead to severe consequences to patient health.

Possible Causes

1. Incorrect mapping.
2. System design prescriber preference.
3. A dose based medication item from secondary care may be converted to the wrong product based medication item in primary care either as a result of human transcription error or as a result of automated / semi-automated conversion.

Existing Controls

Pharmacists may act as a control but may not be able to translate the text into meaningful data and recover the problem.

Design

Human readable rendition of original dose based prescription preserved and presented to primary care prescriber to facilitate cross check.

Test

Clinical validation assurance testing to cover all prescribing formats.

Training

Relevant training materials to be produced/updated by suppliers of secondary and primary care to cover the various prescribing formats.

Business Process Change

All clinicians should review medication message content before accepting into their systems.