Description of Event or Problem · 1
OUR ENDOSCOPY DEPARTMENT HAS HAD PRIOR EXPERIENCES WHEN USING THEIR CAS MEDICAL, VITAL SIGN MONITORS IN A TIMED NIBP MODE. THE ORIGINAL UNDERSTANDING WAS WHEN A NURSE ENTERED A TIMED MODE (USING A 10 MINUTE CYCLE TIME FOR NIBP), THE MONITOR WOULD EXIT OUT OF THIS TIMED MODE AND INTO MANUAL MODE. THIS WOULD LEAVE THE PATIENT CONNECTED TO A DEVICE THAT WAS NOT MONITORING THE PATIENT.OUR ORIGINAL THOUGHT AFTER TALKING WITH THE MANUFACTURER, WAS THERE COULD BE AN ISSUE WITH THE KEYPAD. WE MADE ARRANGEMENTS FOR THE MANUFACTURER TO BRING IN TWO LOANER DEVICES AND WE WOULD CYCLE THROUGH OUR INVENTORY UNTIL ALL OF THE 12 VITAL SIGN MONITORS HAD THEIR KEYPADS REPLACED. WE JUST SENT OUT OUR LAST TWO MONITORS TO THE MANUFACTURER AND FOLLOWED UP WITH OUR ENDOSCOPY DEPARTMENT TO SEE IF THEY HAVE EXPERIENCED ANY CONTINUING ISSUES. OUR TECHNICIAN WAS INFORMED THE ISSUE WAS STILL HAPPENING AND JUST OCCURRED THAT MORNING. OUR TECHNICIAN WAS ABLE TO TRACK DOWN THE NURSE THAT HAD EXPERIENCED THE ISSUE. THE TECHNICIAN TOOK THE EXTRA TIME TO WORK WITH THE NURSE AND ASKED THE RIGHT QUESTIONS AS TO WHAT HAPPENED. IN DOING SO, THE NURSE REVEALED THAT WHEN SHE USES THE VITAL SIGN MONITOR IN A TIMED MODE, SHE ENTERS THE LENGTH OF TIME AND THEN RETRIEVES THE PATIENT. WHEN SHE RETURNS, SHE PRESSES THE START BUTTON TO BEGIN THE TIMED CYCLE. HOWEVER, DURING THIS SIMULATION, THE TECHNICIAN WAS ABLE TO SEE THE TIMED MODE "TIMED OUT" OR EXIT THE TIMED MODE AND RETURNED TO THE DEFAULT MANUAL MODE. IF THE TIMED MODE IS SELECTED, IT WILL BOUNCE YOU OUT AFTER 30 SECONDS OF NOT BEING USED. THE NURSE WAS DOING WHAT SHE THOUGHT WAS RIGHT, AND WE HAD INITIALLY THOUGHT THE EQUIPMENT WAS THE ISSUE. HOWEVER, AFTER TALKING WITH THE STAFF, WE DETERMINED THE TIMING OF THE SEQUENCE THAT THE DEVICE WAS BEING USED WAS CAUSING THE ERROR. OUR TECHNICIAN HANDLED THIS ISSUE IN A PROFESSIONAL MANNER AND WAS ABLE TO SET UP THREE IN-SERVICES WITH THE ENDOSCOPY NURSING STAFF SO THEY CAN BE AWARE OF THIS SCENARIO. WE HAVE NOT HAD THIS ISSUE SINCE THIS DISCOVERY AND WE NOTIFIED THE MANUFACTURER OF THIS MONITOR USE ISSUE.MANUFACTURER RESPONSE FOR MONITOR, PHYSIOLOGICAL, VITAL SIGN, MAXNIBP (PER SITE REPORTER): MANUFACTURER WAS NOT FULLY AWARE OF THIS POTENTIAL PROBLEM. THEY ARE AWARE OF THIS ISSUE AND WILL EVALUATE WHAT STEPS MAY OR MAY NOT BE TAKEN.