Fatal Medication Errors Can Result When Drug Entry Fields Populate after Only a Few Letters

July 7, 2021 | Evaluations & Guidance


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To expedite drug searching and selection, many medication ordering, storage, and delivery systems allow the practitioner to enter only a few letters of a drug name before the system populates the drug selection field with a list of similar drug names.

For instance, when "met" is entered, the display may populate with options such as methylphenidate, methadone, metolazone, methotrexate, metformin, and metronidazole. Similarly, entering "hyd" may yield hydromorphone, hydroxyzine, hydralazine, and hydrocodone as options. In addition, entering "ctx" may lead to cyclophosphamide (Cytoxan) and ceftriaxone being displayed as matches, since they contain the letters entered. Similar behavior is observed when a combination of the first few letters and strength are entered. For example, typing "met10" may yield methadone...

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