It's not just wrong, it's extremely dangerous. In an emergency situations, where morphine is commonly administered for extreme pain, the dosage needed to relieve the pain of a 330lb man would kill a 150lb man. Granted the responder at the patient's side would probably realize something is amiss, but a pharmacist in another room filling an order wouldn't have the context, and could make the error.
My wife's grandmother was killed by a second dose of metformin (well kidney failure after a second dose) because the attending that administered the first dose left the room, planning on coming back a moment later, when the next round nurse came in, they noticed the does hadn't been administered (wasn't in the chart), ordered another dose, and injected it.
There were multiple layers that should have prevented that. The prescription shouldn't have been filled for a second time without someone noticing. The first doctor should have filled in the chart before leaving. And the pharmacist should have noticed that it had already been requested.
Too many patients, too few doctors, and with Epic, too many button clicks.
Ancapistani•48m ago