[20682431]
Patient found to have been discharged from central telemetry unit. This 76 year old indian female was admitted for cva, was s/p pacemaker insertion, being monitored on the telemetry unit. At approx. 2:28 p. M. A strip (ekg) was read on this patient. At approx. 6 pm-patient found to be unresponsive and had palpable pulse. On inspection of equipment - patient found to be discharged from the central telemetry unit & data on patient was irretreivable. Patient was appropriately connected. Four specific steps are necessary to discharge the patient. Staff is very familar with equipment & delay discharging pt. Manuallydevice not labeled for single use. Patient medical status prior to event: fair condition. There was not multiple patient involvement. Device serviced in accordance with service schedule. Date last serviced: 01-sep-91. Service provided by: manufacturer. 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, computer software performance tests conducted, electrical tests performed, performance tests performed. Results of evaluation: none or unknown, telemetry equipment. Conclusion: device evaluated and alleged failure could not be duplicated, none or unknown. Certainty of device as cause of or contributor to event: invalid data. Corrective actions: device repaired and put back in service. The device was not destroyed/disposed of.
Patient Sequence No: 1, Text Type: D, B5