BEUDAMED
    FDA Adverse Event Injury Summary report: N

    SIEMENS PHARMACY

    MDR report key: 1832373 · Received September 5, 2010

    Report

    Report Number
    MW5017360
    Event Type
    Injury
    Date Received
    September 5, 2010
    Date of Event
    September 3, 2010
    Report Date
    September 5, 2010
    Manufacturer
    SIEMENS
    Product Code
    LNX
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    PA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Description of Event or Problem · 1

    THE PT WITH BACKGROUND LUNG DISEASE WAS ADMITTED TO THE HOSPITAL WITH WHEEZING. FROM TWO DIFFERENT SITES IN THE HOSPITAL, TWO DIFFERENT HIGH DOSE PARENTERAL STEROID THERAPIES WERE ORDERED BY TWO DIFFERENT DRS AND ENTERED INTO THE RECORD. THE PT RECEIVED BOTH POTENT STEROIDS FOR 24 HOURS CAUSING ELEVATED BLOOD SUGAR BUT NO OTHER, AS YET, UNTOWARD EVENTS. THE DOSE CHECKING AND RECONCILIATION APPS OF THE EHR, THE PHARMACY ELECTRONIC RECORDS AND CONTROL SYSTEM, THE HUMAN RESOURCES WORKING THE PHARMACY, THE NURSES ADMINISTERING THE MEDICATION, AND THE EXPERIENCED DRS ORDERING AND TREATING THE PT FAILED TO DETECT THE ERROR. NB. DUPLICATE MEDICATIONS HAVE BEEN ADMINISTERED TO PTS WITH ELECTRONIC RECORDS. THE INCIDENCE AND ADVERSE EVENTS CAUSED BY THIS TYPE OF SERIOUS ERROR HAVE NOT BEEN REPORTED IN PEER REVIEWED LITERATURE TO THE BEST OF OUR KNOWLEDGE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 SIEMENS PHARMACY SOARIAN EHR LNX SIEMENS

    Patients

    Seq Age Sex Outcome Treatment
    1 52 YR Hospitalization| O