BEUDAMED
    FDA Adverse Event Other Summary report: N

    DISPILL MULTIDOSE SOFTWARE

    MDR report key: 6092403 · Received November 8, 2016

    Report

    Report Number
    MW5065954
    Event Type
    Other
    Date Received
    November 8, 2016
    Report Date
    July 25, 2016
    Product Code
    NXB
    Report Source
    Voluntary report
    Reporter Occupation
    PATIENT

    Narratives

    Description of Event or Problem · 1

    THIS INVOLVES AN ERROR RELATED TO DISPILL MULTIDOSE SOFTWARE. THE PROGRAM KEEPS A MANUALLY ENTERED MEDICATION PROFILE FOR EACH PATIENT WHO RECEIVES THE DISPILL PACKAGE. WHEN TRYING TO PRINT A DISPILL CARD FOR ONE PATIENT, THEN PHARMACIST ERRONEOUSLY CHANGED THE NAME OF THE PATIENT, THOUGH THEY THOUGHT THEY WERE SEARCHING FOR THE PATIENT. A DIFFERENT PATIENT'S PROFILE HAD BEEN LEFT UP ON THE SCREEN, WHICH ALLOWED THE PHARMACIST TO ALTER THE NAME. WE REACHED OUT TO DISPILL TO SEE IF THERE COULD BE AN AUTO-LOG OUT PUT IN PLACE, SO IF A PATIENT WAS LEFT UP FOR A PARTICULAR AMOUNT OF TIME, THE SYSTEM WOULD LOG OUT. WE WERE TOLD THAT DISPILL WOULD NOT DO THIS HOWEVER. WE DO HAVE OTHER CATCHES INTERNALLY IN PLACE TO MAKE SURE THAT THESE TYPES OF ERRORS DON'T OCCUR, HOWEVER THE PHARMACIST DID NOT FOLLOW THOSE POLICIES. MEDICATION NOT ADMINISTERED TO OR USED BY THE PATIENT. RELEVANT MATERIAL NOT PROVIDED. (B)(6).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    739167 DISPILL MULTIDOSE SOFTWARE DISPILL MULTIDOSE SOFTWARE NXB

    Patients

    Seq Age Sex Outcome Treatment
    1