FDA Adverse Event Injury Summary report: N

VENCOR PROTOUCH

MDR report key: 1711538 · Received April 12, 2010

Report

Report Number
MW5016188
Event Type
Injury
Date Received
April 12, 2010
Date of Event
April 3, 2010
Report Date
April 11, 2010
Manufacturer
VENCOR
Product Code
NSX
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
PA, US
Reporter Occupation
PHYSICIAN

Narratives

Description of Event or Problem · 1

THE VENCOR PROTOUCH COMPUTERIZED ELECTRONIC CARE RECORD AND ORDERING SYSTEM IS DEPLOYED AT ALL LONG TERM ACUTE CARE HOSPITALS UNDER THE OWNERSHIP OF A PUBLICLY TRADED CORPORATION. IT IS SAID TO BE A "HOME GROWN" SYSTEM WITH EXCEPTIONAL FEATURES HIGHLIGHTED BY ANTIQUATED PLATFORMS. NURSES DESCRIBE CLUNKINESS TO CHART PT APPROPRIATE DESCRIPTION WITH LIMITATION TO ACCURACY. THE EQUIPMENT OFTEN FAILS TO TRANSFER ORDERS AND ASSOCIATED COMMUNICATIONS TO THE RECIPIENT WHETHER THAT BE LABORATORY, CONSULTANTS, NURSES, REHABILITATION, AND NUTRITION, RESULTING IN FAILURE TO EXECUTE ORDERS ACCURATELY, IF AT ALL, AND HAS RESULTED IN CASES IN WHICH ERRONEOUS RECORDS BELONGING TO AN ALTERNATIVE PT ARE ELECTRONICALLY APPENDED TO THE INCORRECT PT. THIS SOFTWARE FAILURE IN THE ELECTRONIC ORDERING SYSTEM POSES RISK TO EACH PT THROUGHOUT THE NATIONAL NETWORK OF HOSPITALS AND SAID RISK IS INSUFFICIENTLY REDUCED. A LARGELY OVERLOOKED SOURCE OF ERROR OF ALL ELECTRONIC ORDERING SYSTEMS IS THE COMPUTERIZED TRANSFORMATION OF THE ORDER OR COMMUNICATION BETWEEN PARTIES SUCH THAT THE RECIPIENT GETS THE COMPUTERIZED ALTERED VERSION RATHER THAN THE ORIGINAL DESCRIPTION WITH NEITHER PARTIES SEEING THE SAME SCREEN.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 VENCOR PROTOUCH PROTOUCH CPOE ELECTRONIC RECORD NSX VENCOR * *

Patients

Seq Age Sex Outcome Treatment
1 80 YR Life Threatening