BEUDAMED
    FDA Adverse Event Other Summary report: N

    OMNICELL

    MDR report key: 17389917 · Received July 21, 2023

    Report

    Report Number
    MW5120001
    Event Type
    Other
    Date Received
    July 21, 2023
    Date of Event
    July 20, 2023
    Report Date
    July 20, 2023
    Manufacturer
    OMNICELL, INC.
    Product Code
    NEP
    Report Source
    Voluntary report
    Reporter Location
    FL, US
    Reporter Occupation
    PHARMACIST
    Health Professional
    Yes

    Narratives

    Description of Event or Problem · 0

    OMNICELL DEVICE PRODUCT SELECTION OPENING WRONG POCKET. ORDER WAS FOR IBUPROFEN 400 MG IN OMNICELL DRAWER 10, BIN 10, ORDER WAS VERIFIED BY PHARMACY WHICH SHOULD HAVE DIRECTED THE NURSE TO THE CORRECT POCKET. WHEN NURSE WENT TO THE OMNICELL AND SELECTED THE ORDER, IT OPENED THE AZITHROMYCIN 250 MG POCKET. NURSE IDENTIFIED WRONG DRUG AND DID AN INVENTORY COUNT ON BOTH POCKETS. IDENTIFIED THAT BOTH POCKETS AND THE CORRECT MEDICATION LOADED. WHEN THE NURSE SELECTED THE IBUPROFEN ORDER AGAIN, THE OMNICELL DIRECTED HER AGAIN TO THE AZITHROMYCIN 250 MG POCKET AT WHICH TIME SHE CONTACTED THE PHARMACIST. THE PHARMACIST ADVISED THEM TO POWER OFF THE OMNICELL DEVICE AND TO POWER BACK ON. ONCE THAT OCCURRED, THE NURSE WAS DIRECTED TO AGAIN TRY TO REMOVE THE IBUPROFEN BY SELECTING THE IBUPROFEN PRODUCT AND THIS TIME IT OPENED THE CORRECT IBUPROFEN 400 MG POCKET. DEVICE IS OPENING DRAWER 10 BIN 8 FOR BOTH AZITHROMYCIN 250 MG AND IBUPROFEN 400 MG.(B)(6).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    773533 OMNICELL SYSTEM/DEVICE, PHARMACY COMPOUNDING NEP OMNICELL, INC.

    Patients

    Seq Age Sex Outcome Treatment
    1 44 YR Male AZITHROMYCIN| IBUPROFEN