FDA Adverse Event Injury Summary report: N

MILLENIUM

MDR report key: 1657877 · Received April 7, 2010

Report

Report Number
MW5015514
Event Type
Injury
Date Received
April 7, 2010
Date of Event
November 22, 2006
Report Date
April 7, 2010
Manufacturer
CERNER
Product Code
NSX
Report Source
Voluntary report
Reporter Location
PA, US
Reporter Occupation
PHYSICIAN

Narratives

Description of Event or Problem · 1

HUNDREDS OF ORDERS POPULATE THE ELECTRONIC ORDERING MENU SCREENS OF THE CERNER MILLENIUM CPOE SYSTEM. NAME IDIOSYNCRASIES ARE PREVALENT. STANDARD AND GENERALLY ACCEPTED NAMES OF TESTS AND PROCEDURES ARE SOMETIMES NOT FOUND ON THE MENU. THIS REQUIRES EXTENSIVE HUNT TIME. THERE ARE MEDICATIONS LISTED THAT NO LONGER EXIST. CERNER DOES NOT APPEAR TO KEEP THE LISTINGS ON ITS ORDER MENU CURRENT. IN A CASE OF ANION GAP ACIDOSIS, IT WAS INDICATED TO ASSESS THE SERUM FOR KETONE BODIES. ENTERING K-E-T-O-N-E B-O-D-I-E-S ENLIGHTENED THE SCREEN WITH "KETONES -ACETONE LEVEL-". IT WAS CLICKED AND WITH MULTIPLE SUBSEQUENT CLICKS, IT WAS ORDERED. THE RESULT APPEARED ON THE LABORATORY SCREEN GRID AS "ACETONE" "NEG". THERE ARE THREE KETONE BODIES, EACH INDICATING A UNIQUE REDOX STATE, BUT CERNER'S CPOE DEVICE ONLY ALLOWS ORDERING ONE OF THE THREE. FREE TEXT ORDERING OF LAB TESTS WITH SPECIFICATIONS ARE NOT ACCESSED BY THE LAB AND IN GENERAL ARE NOT COMPLETED. IN SUMMARY, THERE ARE CARE LIMITING AND PT ENDANGERING DEFECTS INVOLVING THE ORDERING MENU FOR THIS CPOE SYSTEM.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 MILLENIUM POWERCHART CPOE NSX CERNER

Patients

Seq Age Sex Outcome Treatment
1 70 YR Hospitalization| L