[1141]
The activation of the generator and manual operation of the transfer switches once the generator is operational is performed on a monthly basis to test emergency generators. The normal building power remains "on" and only a momentary fluctuation occurs at the moment of transfer of the emergency power circuits to the generator. The specifications of the telementry equipment state sthey must operate without failure through a atransfer of power; and they have previously done so without complication. On one patient care unit, the central telemetry computer receivers locked up when the power was transferred. Other telemetry patient care units were unaffected. To "unlock" the unit telemetry, a biomedical instrumentation technician had to turn off, then back on, each individual telemetry computer receiver on the unit and then the unit system became operational. The actual equipment failure was in the monitoring branch exchange and the receivers in the telemetry system. Shortly after the equipment failed, a patient suffered cardiac arrest and diedinvalid data - regarding single use labeling of device. Patient medical status prior to event: critical condition. There was multiple patient involvement. Number of patients involved:. Device serviced in accordance with service schedule. Date last serviced: 01-oct-92. Service provided by: user facility biomedical/bioengineering department. Service records available. No imminent hazard to public health claimed. Device used as labeled/intended. Device was evaluated after the event. Method of evaluation: actual device involved in incident was evaluated, visual examination, other. Results of evaluation: electrical problem, telemetry failure, telemetry equipment. Conclusion: device failure indirectly contributed to event. Certainty of device as cause of or contributor to event: maybe. Corrective actions: device repaired and put back in service. The device was not destroyed/disposed of.
Patient Sequence No: 1, Text Type: D, B5