QSRS
Medication dose display mismatch
Barcode workflow showed a dose inconsistent with the active order; administration paused pending Pharmacy verification.
Submitted details
- File ID
- 1010
- File type
- QSRS
- Event date
- 2026-07-30
- Submission timeliness
- 1 calendar day after event Contributes to overall submission-timeliness metrics.
Brief factual description
During medication administration, the barcode workflow displayed a 20 mg dose while the active order showed 2 mg. Administration was paused. Pharmacy verified the order before medication was given.
- Spoke up
- Yes
- Spoke up description
- I paused the workflow and contacted Pharmacy to verify the active order before the medication was given.
Patient
- Name
- Avery Morgan
- DOB (age)
- 2018-07-12 (8 years)
- MRN
- 8013421
- Patient lookup
- Epic patient lookup · confirmed at submission
Classification and review
- Event type
- Medication safety · dose discrepancy
- Patient harm
- CHCO adaptation Category C · Patient Safety signoff complete
- Responsible area
- Department · Main Campus Pharmacy · responsible for file closure
- Additional review areas
- Department · Acute Care Unit 7; Department · Medication Safety Informatics
- Current event-file status
- Level 1 review · in progress
- Review response
- Pharmacy verified the order and barcode configuration. Nursing review is due 2026-08-07.
Actions
- Verify barcode configuration across the medication profile — in progress.
- Share verified learning with affected teams — waiting for review completion.
Your uploaded attachments
- SYN-barcode-screen.png · image · accepted 2026-07-31
- SYN-order-detail.pdf · document · accepted 2026-07-31
Related file history
Automated trigger
1011 · linked as related
Human decision on 2026-07-31: related evidence, not a duplicate. The automated-trigger file remains separate from your original QSRS file.