MAUDE Adverse Event Report: EPIC; NONE

Device Problem Application Program Problem: Medication Error (3198)

Patient Problem Missed Dose (2561)

Event Type  Other  

Event Description

In (b)(6) of this year, a pharmacist verifying a medication order for hydroxychloroquine in epic noticed that the header read "alternative accepted, reordered from quinine." upon investigation, it was determined that the pt had been taking quinine for leg cramps prior to admission.The medication was entered on the pt's med list in epic.During admission medication reconciliation, the surgeon attempted to order quinine to continue as an inpatient order.Quinine is a non-formulary product in our system, so epic presented the surgeon with a recommended alternative of hydroxychloroquine.Because the physician was not familiar with the products, he assumed that hydroxychloroquine as our formulary alternative for quinine and ordered it to be given inpatient.The pharmacist contacted the provider for clarification, and the order was changed to the correct product.In (b)(6) (2 months later), a similar event was reported.A pharmacist verifying a medication order for pyrimethamine in epic noticed that the header read "alternative accepted, reordered from primaquine." this pt had been taking primaquine for pneumocystis jiroveci pneumonia prior to admission.During admission medication reconciliation, the physician attempted to reorder the medication from the pt's prior to admission medication list.Because primaquine is non-formular, epic provided the physician with the alternative of pyrimethamine which does not have a recommendation for pneumocystis jiroveci pneumonia.The pharmacist contacted the provider for clarification of the order, and primaquine was ordered.Both of these instances occurred due to the dynamic lma functionality in epic.The system first looks for formulary generic alternatives.If none are found, it then looks for alternatives based on pharmaceutical subclass that is assigned by medispan.This pharmaceutical subclass in medispan may be different from ahfs subclasses.In both cases, anti-malarial subclass designation drove the recommended alternatives.Our system has recently decided to disable the dynamic lma functionality in epic due to these and other similar instances that have occurred throughout of system.Patient counseling provided: unk.(b)(4).

• Brand Name: EPIC
• Type of Device: NONE
• MDR Report Key: 4189161
• MDR Text Key: 5026335
• Report Number: MW5038640
• Device Sequence Number: 1
• Product Code: JQP
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Voluntary
• Reporter Occupation: Other
• Type of Report: Initial

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: No
• Device Operator: Other
• Initial Date Manufacturer Received: Not provided
• Initial Date FDA Received: 10/15/2014
• Patient Sequence Number: 1
• Treatment: HYDROXYCHLOROQUINE; QUININE; PYRIMETHAMINE; PRIMAQUINE