Table 2
Percentage of Pharmacy Computer Systems That Failed to Provide Unsafe Order Alerts*
| Order | Unsafe Order Not Detected | Can Override Without Note |
| Cephradine oral suspension IV | 61 | 36 |
| Ketorolac 60 mg IV (patient allergic to aspirin) | 12 | 64 |
| Vincristine 3 mg IV x 1 dose (2-year-old) | 62 | 56 |
| Colchicine 10 mg IV for 1 dose (adult) | 66 | 55 |
| Cisplatin 204 mg IV x 1 dose (26-kg child) | 63 | 62 |
-
↵* All these orders are unsafe and have resulted in at least one fatality in the United States. However, most pharmacy systems did not detect them, and even among those that did, a large percentage allowed an override without a note. Data reprinted, with permission, from ISMP Medication Safety Alert! Feb 10, 1999.36 Copyright © Institute for Safe Medication Practices.
