EMRs and duplicates

More offices are making the change to electronic medical records, including writing prescriptions. The Ministry of Health is currently investigating options for e-prescribing and this direction is supported by all of the colleges that regulate prescribers. Until the legislation changes, duplicate prescriptions must still be used for controlled medication. 

Some physicians are looking at innovative ways to program EMR software to print duplicate prescriptions; however, getting them to print correctly can be a challenge. Recently, a duplicate prescription for Kadian was printed from an EMR, which resulted in a medication error. The duplicate prescription contains two separate fields: Drug Name and Strength and Directions for Use. Under Drug Name and Strength, the drug name was entered but not the strength; instead, the daily dose was entered in the wrong place. The prescription, as written, was dispensed as 700mg (seven capsules) and the patient took all seven capsules as a single dose. Fortunately, the patient was unharmed. 

To illustrate:

Original prescription

Safest way to write prescription

This incident reminds physicians to complete all of the fields on a prescription correctly, including one generated from an EMR.