[21381209]
While being monitored on the telemetry step down unit, a patient suffered a ventricular arrhythmia. Nurses seated at the monitoring system stated that at the onset of the arrhythmia, the monitoring system failed to alarm or cause a graph to be generated. The graph was manually activated and a medical express team called immediately. The patient died subsequent to the express team resuscitation efforts. The telemetry unit, reciever and monitor involved was evaluated by the biomedical engineering division and no defect was founddevice not labeled for single use. Patient medical status prior to event: critical condition. There was not multiple patient involvement. Device serviced in accordance with service schedule. Date last serviced: 01-mar-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, electrical tests performed, performance tests performed, visual examination. Results of evaluation: none or unknown. Conclusion: device evaluated and alleged failure could not be duplicated, no failure detected and product within specification. Certainty of device as cause of or contributor to event: invalid data. Corrective actions: user education provided, inserviced by other facility staff. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5