device manufacturer had programmed a monitoring
alarm function so it was in the “off” position and had not made
this known to the hospital at the time of purchase. This “off” position prevents
the alarm from signaling in the event of a low or failed
battery or when the device’s leads become disconnected from the
patient. An adverse patient outcome
occurred when the unit’s alarm did not signal a problem and there was
delay in treating a patient.
that all hospitals work closely with their clinical and biomedical staff and manufacturers of monitoring equipment to put systems in place to ensure that all alarm functions are appropriately programmed and used in the “on” position and are
tested frequently to verify they are in the “on” position.
Based on information reported into
the Patient Safety Registry, the Minnesota
Hospital Association has worked with
the members of MHA’s Patient Safety & Registry
Advisory Council to prepare this alert.
For more information on the Patient Safety Registry, adverse health event reporting
or this alert, contact Julie Apold,
MHA patient safety registry manager,
at email@example.com or (651) 641-1121
or toll free at (800) 462-5393.