BEUDAMED
    FDA Adverse Event Injury Summary report: N

    CPOE/EHR DEVICE

    MDR report key: 3955739 · Received July 21, 2014

    Report

    Report Number
    MW5037371
    Event Type
    Injury
    Date Received
    July 21, 2014
    Date of Event
    July 18, 2014
    Report Date
    July 20, 2014
    Manufacturer
    PRO TOUCH/KINDRED
    Product Code
    NSX
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    PA, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Description of Event or Problem · 1

    IN A CASE WITH DETERIORATING KIDNEY FUNCTION, RESPIRATORY FAILURE, AND ALIMENTARY TRACT CANDIDIASIS, EVAL AND MANAGEMENT ORDERS WERE ENTERED VIA THE CPOE MACHINE FOR ANALGESIA, GENITO-URINARY FUNCTION, AND PULMONARY FUNCTION. THESE ORDERS WERE SPORADICALLY EXECUTED, COMPROMISING THE CARE OF THE PT AND DELAYING DIAGNOSIS. THERE IS CONFUSION AND BEFUDDLEMENT IN NURSES WHO MAY BE INADEQUATELY TRAINED ON THESE DEVICES OR OVERWHELMED BY THE EXCESS VERBIAGE ACCOMPANYING THE ORDERS ON THEIR SCREEN, LIMITING THEIR UNDERSTANDING OF WHAT NEEDS TO BE DONE AND WHEN. THE PT WAS NEGLECTED, SUSTAINING SEVERE HYPOXIA FURTHER COMPROMISING THE PT FUNCTION AND PROGNOSIS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    426425 CPOE/EHR DEVICE CPOE NSX PRO TOUCH/KINDRED

    Patients

    Seq Age Sex Outcome Treatment
    1 71 YR Life Threatening