Medication Errors

Nurses General Nursing


We have had a recent trend in medication errors. The hospital that I work in continues to use a physician order sheet with a carbon sheet that is torn off and sent to the pharmacy. We are finding that many of these errors are due to these carbon sheets. One error was noted when the different set pre-printed orders on the carbon was attached to the front order sheet. This was an error in the printing process. My question is: Does your hospital still use paper order sheet with a carbon sheet that is sent to the pharmacy? Or are you all computerized? Are you using CPOE(computerized physician order entry) Thanks Sue


23 Posts

Wow, carbon sheets, that does sound scary!

My hospital is in transition to computer right now and it's a real headache. They say it will all be worth it when its complete and the system will be so much easier, but currently the MD writes orders, it's faxed to the pharmacy and anything besides drugs has to be ordered in the computer, the unit secretary signs it off, then the nurse signs it off. It is not a perfect system, things get missed or transcribed wrong all the time. They say the docs will have to put their orders into the computers soon :roll

Yeah, that'll happen! Our docs are too lazy now to write it down, no way are they going to log on to the computer and type it out. They will give us more verbals, which we all know the repercussions of that!

Actually, I have heard of one system in some hospital where the docs all have PDA's and they input their orders in those, but then where is the MD_RN communication? I don't know what the solution is!

jnette, ASN, EMT-I

4,388 Posts

Specializes in Hemodialysis, Home Health.

Our orders are scanned to the pharmacy.

Secretary puts them in the computer and also scans it down to the pharmacy, then it goes back into the chart. Nurse verifies it's in the computer and signs off on the chart.

I'd LOVE to have the docs put their orders in the computer... at least I'd be able to READ them !!! :rolleyes:

Sue McGann

12 Posts

Thanks for the quick replies. We used to enter everything into the computer but have realized that it was an unlicensed person( Unit secretary) doing this and have rethought the process. Now we want to get the order to the pharmacy for the pharmacist type person to enter in the order. Another problem we have found is that when faxing the addressograph patient information become illegible. Do you have the same problem?:eek: :eek:

jnette, ASN, EMT-I

4,388 Posts

Specializes in Hemodialysis, Home Health.

As far as the unit secretary entering the order into the computer... it still MUST be verified by a nurse (who goes into the computer and verifies they are correctly entered) and then noted as verified on the chart. This is the double check. After the order has been scanned to the pharmacy, the pharmacist enters the order into the pyxis.

Haven't been aware of any addressograph problems, as they are scanned and not faxed.. might be a better system than faxing?


475 Posts

Our docs put all orders into computers. They go under pharmacy, then the type of drug they want (for example,"antibiotics") then the drug. The drug name, route, dosage, etc, is already written out, and they just click on it. They can type in the drug w/ a different dosage, but if it is wrong, the pharmacy will call them on it and question them. (For example, if the doc types in "Vistaril 25 mg IVP the dr will be called)

This usually works well for us, altho in ED orders are still written out.


615 Posts

We used to use the carbons, yellow for pharmacy, pink for the nurse.

Now the original order is scanned or faxed (what's the difference?) to pharmacy, and a copy of the order is made and given to the floor nurse.

allnurses Guide

Spidey's mom, ADN, BSN, RN

11,302 Posts

I think we use Physician Orders like you are describing as "carbons" . . of course I'm thinking you are talking about actual carbon paper between sheets of white paper. :eek:

Our orders are written by the physician in illegible writing or written by a nurse who was given a verbal order. The ward clerk gets the chart first, notes it, writes the lab or xray slips, writes the new orders on the kardex, tears off the white copy for pharmacy and yellow for the nurse, puts those into a slot on a wall box container, then hands the nurse the chart who then checks everything and notes it. Pharmacy techs come by the nurses station during the day to check the box or we call down there or a nurse walk it down if we need it faster.

We have a new computer program for pharmacy that we chart our meds in and it is a monumental pain in the tush. Takes forever to get where you need to go . . NOT user friendly. I wish I could just write stuff down the old fashioned way.

If someone would invent a user friendly version, I'd sure appreciate it. It takes so very much longer to do simple things when it is computerized.


BadBird, BSN, RN

1,126 Posts

Specializes in Critical Care.

We fax our orders to the pharmacy.


160 Posts

Our hospital is in the process of changing to CPOE ~ our floor is still using the handwritten order sheets with the copy going to pharmacy.

The unit secy also enters all orders (non medication) into the computer. In addition to signing off the orders in the charts, we have to electronically sign the orders in the computer.


303 Posts

Originally posted by jnette

Our orders are scanned to the pharmacy.

I am starting a new position and this is the way the entire hospital system works...scanning. I am also excited because they use emar! I heard wonderful things about it :cool: The only down side was that one has to go into and out of the Meditech charting to access it :rolleyes: ...but I am regressing! :p


8 Posts

Where I work we still use carbon copies. It is so hard to read some of the Dr's handwriting- there must be a seperate major in college for that, LOL!:rolleyes:

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