At the recently held MSOS Member Meeting during the ASHP Medication Safety Collaborative in Minneapolis on June 4, 2017, a member shared an occurrence that happened in their facility. The member believed that a defect in BD’s (Pyxis) MedStation ES software resulted in the misinterpretation of an order frequency intended to be every Monday, Wednesday and Friday as every day that was associated with a patient incident. David Swenson, Vice President, Clinical Strategy, Medical Affairs, Medication Management Systems at BD attended that meeting and publicly volunteered to investigate the report. David shared his investigation and below is an excerpt of his findings. David offered to answer any further questions or concerns regarding this investigation. You can contact him at David.Swenson@bd.com.
Thank you for the opportunity to report back on the medication incident that was reported during the ASHP Summer meeting in Minneapolis.
I attended this session and personally committed to reporting this occurrence back to the BD offices. BD considers patient safety its highest priority, and the investigation of the issue commenced as soon as I reported it.
We were able to reach the member’s pharmacy organization who informed us that this issue was the result of misconfiguring frequency settings on the ES Server after they had gone live, which was corrected as soon as the occurrence was discovered. The individual assured us that the problem was not the result of a defect in the ES software
I am therefore happy to report that the customer involved was able to address the matter as soon as it was discovered.