PYXIS ES
Received Nov 11, 2016
Report MW5066025 · MDR key 6102228
Device
Generic name
Pyxis Es
Manufacturer
Bd / CarefusionProduct problems
- Data Problem
- Patient Data Problem
- Application Program Problem: Medication Error
Patient
Not reported
- No Information
- No Information
Narrative
Description of Event or Problem
I WANTED TO REPORT A SUBOPTIMAL DESIGN ISSUE WITH PYXIS ES THAT HAS CONTRIBUTED TO ERRORS AT OUR HOSPITAL. UNLOAD/LOAD TRANSACTIONS WHEN A NEW MEDICATION IS PEND LOADED ON TOP OF A MEDICATION TO BE UNLOADED, PYXIS AUTOMATICALLY SCHEDULES THE TRANSACTIONS SO THAT THE UNLOAD TRANSACTION IS IMMEDIATELY FOLLOWED BY THE SUBSEQUENT LOAD (WHILE POCKET IS STILL OPEN FROM UNLOAD TRANSACTION). THERE IS NO WAY TO PERFORM ALL UNLOAD TRANSACTIONS, THEN GO BACK AND DO THE LOAD TRANSACTIONS. THIS WORKFLOW IS QUICKER (TOUCH EACH POCKET ONCE). HOWEVER, WE HAVE HAD NUMEROUS CASES WHERE THE TECH FORGETS TO REMOVE THE MEDICATION TO BE UNLOADED BEFORE PUTTING THE NEW MEDICATION INTO THE POCKET. MEDICATION ADMINISTERED TO OR USED BY THE PT: NO. (B)(4). REF: MW5066024.