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There's a “bug” in my code.

From the March 9, 2006 issue

Programming codes that cause unintended consequences in application software are often referred to as "code bugs." We recently learned about a "code bug" with Abacus™ TPN Calculation Software used with the Baxa Compounder. A pharmacist entered a weekly dose of vitamin K (phytonadione) into a patient's TPN profile, to begin the next day. Shortly thereafter, the physician decided to discontinue the vitamin K, so the pharmacist reduced the dose to zero in the TPN profile. The prior order for vitamin K did not appear on the printed label, but it still appeared on the corresponding system-generated compounding sheet at the original dose. The pharmacist corrected the error before the TPN was prepared, but the reporter, and later ISMP, contacted Baxa. As a result, the manufacturer recently sent a letter to all users describing the problem and strategies to avoid this "code bug" until the next version (available in mid-April) corrects it. We applaud this effort, as software vendors have not always informed all users of newly recognized "code bugs" in a timely fashion. The information may simply be posted on the company's website, or it may remain between the reporting client and the vendor. It's important for companies to actively disclose when code issues are discovered if they can affect patient safety. We encourage you to check with current and prospective information system software vendors to learn about their policies for communicating such information and how you can retrieve it.


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