BEUDAMED
    FDA Adverse Event Injury Summary report: N

    HMM

    MDR report key: 2431076 · Received January 25, 2012

    Report

    Report Number
    MW5024002
    Event Type
    Injury
    Date Received
    January 25, 2012
    Date of Event
    January 1, 2011
    Report Date
    December 14, 2011
    Product Code
    OUG
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    ISMP MEDICATION ERRORS REPORTING PROGRAM. IN OUR HOSPITAL WE HAVE TWO COMPUTER SYSTEMS WHERE ALLERGIES ARE LISTED. ONE IS USED FOR THE INPATIENT ADMISSIONS AND ONE IS USED IN THE EMERGENCY ROOM. THERE IS AN INTERFACE ISSUE WITH THESE COMPUTER SYSTEMS AND THEY DO NOT COMMUNICATE WITH ONE ANOTHER. ALSO, WE CHANGED THE INPATIENT PHARMACY COMPUTER SYSTEM IN XXXXXXXXX 2010. WHEN A PATIENT IS ADMITTED NOW, IF THEY WERE PREVIOUSLY ADMITTED THE OLD SERIES COMPUTER SYSTEM, ALLERGY INFORMATION FLOWS INTO THE NEW (B)(6) PHARMACY COMPUTER SYSTEM AND (B)(6) CLINICAL (HOSPITAL WIDE SYSTEMS) AND ALLERGIES ARE UPDATED AND VERIFIED BY PHARMACISTS. HOWEVER, NEITHER OF THESE SYSTEMS COMMUNICATES (NOT INTERFACED) WITH THE ER SYSTEM. WE HAD A PATIENT ADMITTED TO OUR HOSPITAL ON (B)(6) 2010 WHO HAD AN ALLERGIC REACTION TO AVELOX (MOXIFLOXACIN) DURING THIS ADMISSION. AT THAT TIME THE PATIENT'S ALLERGIES WERE UPDATED IN THE SERIES COMPUTER SYSTEM AND WERE ADDED TO THE PATIENT'S FACESHEET WHICH IS PRINTED WITH EACH SUBSEQUENT ADMISSION. THE PATIENT WAS BROUGHT TO THE ER ON (B)(6) 2011 (ABOUT 6 MONTHS LATER) AND AGAIN RECEIVED AVELOX DESPITE HAVING THE ALLERGY LISTED IN THE SERIES COMPUTER SYSTEM AND ON THE FACESHEET. THE PATIENT DID NOT HAVE ALLERGIES LISTED IN THE ER COMPUTER SYSTEM AT THIS TIME. THE PATIENT WAS BROUGHT INTO THE ER AGAIN ON (B)(6) 2011 (ABOUT A MONTH AFTER) AND AGAIN RECEIVED AVELOX. SHE HAD A THIRD ALLERGIC REACTION AND HAD TO BE TREATED AT THAT TIME FOR THIS REACTION. AGAIN THE PATIENT'S ALLERGIES WERE LISTED IN THE HOSPITAL SYSTEM AND ON THE FACE SHEET BUT NOT IN THE ER SYSTEM. OF NOTE, THE PATIENT WAS SEEN IN OUR ER 13 TIMES BETWEEN THE INITIAL ALLERGIC REACTION ON (B)(6) 2010 AND THE MOST RECENT EVENT ON (B)(6) 2011. OBVIOUSLY, THERE WERE MANY OPPORTUNITIES FOR ALLERGY INFORMATION TO BE RECONCILED IN THIS PATIENT THAT WAS MISSED. WE HAVE SINCE CHANGED OUR PROCESS, ER NURSES ARE NOW REQUIRED TO CHECK ALLERGIES IN BOTH THE ER SYSTEM AND THE HOSPITAL SYSTEM FOR ANY PATIENT WHO PRESENTS. WE THOUGHT IT APPROPRIATE TO REPORT THIS BECAUSE WITH MANY HOSPITALS GOING TO MORE ELECTRONIC SYSTEMS IT IS VERY IMPORTANT TO REALIZE THAT THERE MAY BE ISSUES WITH PATIENT INFORMATION BEING COMMUNICATED BETWEEN THE SYSTEMS. IT IS ALSO VERY IMPORTANT TO EDUCATE STAFF ON THESE ISSUES AND PUT IN PLACE POINTS OF CHECK (E.G. CHECKING THE MULTIPLE SYSTEMS WHERE INFORMATION MAY BE DOCUMENTED, INTERVIEWING THE PATIENT WITH EACH ADMISSION TO OBTAIN CURRENT ACCURATE MEDICAL INFORMATION, TELLING THE PATIENT THE NAMES OF THE MEDICATIONS YOU ARE ADMINISTERING, ETC) TO PREVENT THESE ERRORS FROM OCCURRING. (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 HMM PHARMACY COMPUTER SYSTEM OUG
    2 SERIES COMPUTER SYSTEM OUG
    3 HORIZON CLINICALS HOSPITAL WIDE COMPUTER SYSTEM OUG

    Patients

    Seq Age Sex Outcome Treatment
    1