MAUDE Adverse Event Report: BD / CAREFUSION PYXIS ES

Device Problems Data Problem (3196); Patient Data Problem (3197); Application Program Problem: Medication Error (3198)

Patient Problem No Information (3190)

Event Type  Other  

Event Description

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.

• Brand Name: PYXIS ES
• Type of Device: PYXIS ES
• Manufacturer (Section D): BD / CAREFUSION
• MDR Report Key: 6102228
• MDR Text Key: 60078876
• Report Number: MW5066025
• Device Sequence Number: 1
• Product Code: NZH
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Voluntary
• Type of Report: Initial
• Report Date: 08/19/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/11/2016
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: No
• Device Operator: No Information
• Type of Device Usage: N
• Patient Sequence Number: 1