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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: SCRIPTPRO SCRIPTPRO; TELEPHARMACY
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SCRIPTPRO SCRIPTPRO; TELEPHARMACY Back to Search Results
Device Problem Data Problem (3196)
Patient Problem No Known Impact Or Consequence To Patient (2692)
Event Date 03/24/2015
Event Type  malfunction  
Event Description
Pt received atenolol instead of benztropine.A drug utilization report run in scriptpro identified that since (b)(6) 2015, five scripts filled with the drug name "benztropine 1mg tab golden state" product code "(b)(4)".The (b)(6) bulk bottle of atenolol 25mg had the same ndc leading us to believe the drug was cross linked.We identified one other pt who may have received the wrong drug within the past two weeks.(b)(6) service rep from scriptpro, retrieved the other pts' info and informed us that (b)(6) has been utilizing old ndc's which were originally used for other medications, but did not know the reason behind it.He also confirmed that he had seen one other case of this and that since the cell label showed atenolol 25mg, the cell was filled correctly.When the drug file was updated overnight, scriptpro overwrote the info we entered with the info for the old ndc, effectively changing the cell to identify as, and fill for, benztropine 1mg.When we asked (b)(6) if scriptpro would be notifying their end users, he replied it was causing a large commotion at scriptpro and they were trying to take care of it on their end.This error was a direct result of (b)(6) reusing old ndc numbers for different medications.
 
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Brand Name
SCRIPTPRO
Type of Device
TELEPHARMACY
Manufacturer (Section D)
SCRIPTPRO
MDR Report Key4664142
MDR Text Key5604435
Report NumberMW5041851
Device Sequence Number1
Product Code LNX
Reporter Country CodeUS
Number of Events Reported1
Summary Report (Y/N)N
Report Source Voluntary
Reporter Occupation Pharmacist
Type of Report Initial
Report Date 03/30/2015
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received03/30/2015
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Other
Was Device Available for Evaluation? Yes
Is the Reporter a Health Professional? Yes
Patient Sequence Number1
Treatment
ATENOLOL 25MG, (B)(6)
Patient Age55 YR
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