Near miss

EMRs and electronic prescribing have long been hailed as "safer" than the alternative. While I'm not against both of those in theory, assuming that all variations of them are inherently safer is flawed. Some software might be better. Some might be worse. Even electronic orders must at some point be read and interpreted by a human.

Today a pharmacist dispensed a prescription to a patient of mine labeled thus:

methotrexate 2.5mg tablets, take by oral route, 4 tablets twice a day for 7 days, #56, refills 1

I am not sure, but I think that dose could be lethal.

The prescription as written in my EMR and sent electronically was thus:

methotrexate 2.5mg tablets, take 8 tablets by mouth every 7 days, 1/2 in the morning and half at night, #40, refills 1