BEUDAMED
    FDA Adverse Event Other Summary report: N

    CERNER AMBULATORY POWERCHART

    MDR report key: 2423586 · Received January 12, 2012

    Report

    Report Number
    MW5023831
    Event Type
    Other
    Date Received
    January 12, 2012
    Date of Event
    November 27, 2011
    Report Date
    January 12, 2012
    Manufacturer
    CERNER
    Product Code
    NSX
    Report Source
    Voluntary report
    Reporter Location
    LA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Description of Event or Problem · 1

    USE OF NEW COMPUTERIZED RECORD INVOLVES SCANNING IN LAB DATA. THYROID LEVEL WAS ENTERED INTO WRONG PATIENT'S CHART. WHEN SENT FOR REVIEW, I REQUESTED IT TO BE ERRORED AS ON WRONG CHART. IT WAS BUT THERE IS NO DISTINCT MARKING. I RETURNED TO THE CHART A FEW WEEKS LATER TO PREPARE A REFERRAL LETTER AND IN REVIEWING LAB SAW THE ABNORMAL THYROID LEVEL AND SENT NOTE TO MY NURSE TO CALL FAMILY AND START ON THYROID WITH FOLLOW UP LEVEL. I STARTED A VERY LOW DOSE DESPITE A VERY HIGH TSH BECAUSE HE IS OVER (B)(6). MY NURSE WAS SURPRISED AT THE MISSED LAB AND IN REVIEWING COULD NOT FIND THE RESULT. ERRORED SCANS ARE NOT VISIBLE IF USING ONLY ACTIVE DOCUMENT BUT IF VIEWING ALL DOCUMENTS THEY SHOW WITHOUT VISIBLE ERRATA MARKING. I HAVE REQUESTED CERNER MAKE CHANGES BUT THEY INFORM ME TO REQUEST AN ENHANCEMENT. I'VE REQUESTED THE PATIENT RETURN FOR REPEAT LAB BUT HE HAS NOT. I SUSPECT HE WANTS TO FIND A DOCTOR WHO IS NOT USING A COMPUTER AT THIS POINT. IT TOOK SO LONG TO DO HIS VISIT WITH THE NEW SYSTEM AND NOW THIS ERROR, MAKES ME WONDER WHY I AGREED TO START USING THEM.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CERNER AMBULATORY POWERCHART EHR NSX CERNER NA

    Patients

    Seq Age Sex Outcome Treatment
    1 66 YR