BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HNA MILLENNIUM POWER ORDERS

    MDR report key: 358222 · Received October 22, 2001

    Report

    Report Number
    1931259-2001-00002
    Event Type
    Malfunction
    Date Received
    October 22, 2001
    Date of Event
    October 3, 2001
    Report Date
    October 19, 2001
    Manufacturer
    CERNER CORPORATION
    Product Code
    MMH
    Removal / Correction Number
    NA
    Report Source
    Manufacturer report
    Reporter Location
    MO, US
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    PLEASE SEE INITIAL REPORT.

    Description of Event or Problem · 1

    A USER ENTERED AN ORDER DURING THE ORDER ENTRY PROCESS, WITH A FREQUENCY OF EVERY 8 HOURS AND THEN USED THE AD HOC SCHEDULING FEATURE TO MODIFY THE DEFAULTED ADMINISTRATION TIMES FOR THAT FREQUENCY. AFTER THIS WAS DONE, THE USER CHANGED THE FREQUENCY OF THE ORDER TO A 12-HOUR FREQUENCY WITHOUT MODIFYING THE AD HOC ADMINISTRATIONS TIMES. THE SOFTWARE DID NOT CLEAR THE PREVIOUSLY ENTERED AD HOC ADMINISTRATION TIMES TO ADJUST TO THE DEFAULT TIMES FOR THE NEW FREQUENCY. THIS RESULTED IN A PATIENT RECEIVING A MEDICATIONS 3 TIMES A DAY AS OPPOSED TO 2 TIMES A DAY. THE DRUG WAS CARBAMAZEPENE. THIS INCORRECT ORDER FREQUENCY WAS REPEATED FOR 3 DAYS, ULTIMATELY RESULTING IN THE PATIENT RECEIVING OF TOTAL OF 3 EXTRA DOSES OVER A 3-DAY PERIOD (1 EXTRA DOSE PER DAY). ON THE FOURTH DAY, THE NURSE CARING FOR THE PATIENT NOTICED THE INCONSISTENCY IN THE ORDER AND CONDUCTED A FURTHER INVESTIGATION WITH THE PHARMACIST. THE PATIENT WAS DISCHARGED ON TIME; NO EXTENDED STAY WAS NECESSARY AS A RESULT OF THE OVERMEDICATION. THE PATIENT'S CARBAMAZEPENE LEVELS WERE CHECKED DURING A FOLLOW-UP VISIT THAT OCCURRED 5 DAYS AFTER DISCHARGE, AND WERE NOTED AS NORMAL AT THAT TIME.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    47565 HNA MILLENNIUM POWER ORDERS SOFTWARE MMH CERNER CORPORATION RELEASE 500 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 53 YR Other