In our CPOE system, a medication order was generated for warfarin 7 mg daily. Using an HL7 interface message, the medication order was communicated to an external pharmacy system. Because th

In our CPOE system, a medication order was generated for warfarin 7 mg daily. Using an HL7 interface message, the medication order was communicated to an external pharmacy system. Because there was no dispensable product of warafin 7 mg, the pharmacist converted the order into dispensable products, a 5-mg tablet and a 2-mg tablet. Several days later, clinicians observed that the patient’s anticoagulation laboratory results (INR) were at panic levels, but there had been no easily identified originating event. The anticoagulation medications were reviewed and the clinicians were surprised at the warfarin dosing-it was much higher than originally ordered. The clinicians ordered a dose of warfarin 7 mg daily, yet the order and the eMAR both indicated a dose of warfarin 14 mg. Upon review of the audit trail, the provider entered warfarin 7 mg, but after the pharmacy verification, the order was modified to warfarin 14 mg. The first step was to implement an immediate workaround, which was to discontinue the order and reenter the medication order differently. Because the medication dose required two separate products to be dispensed (warfarin 2 mg and 5 mg), the order was reentered successfully as two separate medication orders.
What are some lessons learned?
What could have been done to prevent this from happening?