Description of Event or Problem · 1
REPORTEDLY AN INFANT WAS NOTED BY CLINICAL STAFF TO HAVE A POSSIBLE "ARRHYTHMIA" ACCORDING TO AN EKG MONITOR. THE DAY NURSE CHANGED THE EKG LEADS AND MONITOR & THE "ARRHYTHMIA" PATTERN DISAPPEARED. DURING THE EVENING SHIFT, THE ABNORMAL PATTERN REAPPEARED, AT WHICH TIME THEY CHANGED THE EKG LEADS, MONITOR, AND ELECTRICAL OUTLET INTO WHICH THE BED WAS PLUGGED, AS WELL AS THE PHYSICAL LOCATION OF THE BED, YET THE PROBLEM REMAINED. THE ATTENDING NEONATOLOGIST INTERPRETED THE PATTERN ON THE MONITOR AND THE EKG LEAD AS ATRIAL FLUTTER/FIBRILLATION AND ORDERED 50 MCG ADENOSINE IV WHICH WAS GIVEN AS ORDERED. UPON ADVICE OF THE CARDIOLOGIST THE BED WAS TURNED OFF (IT HAD BEEN IN AIR CONTROL INCUBATOR MODE) & THE ABNORMAL PATTERN DISAPPEARED. NO COMPROMISE IN VITAL SIGNS WERE EVER NOTED BY CLINICAL STAFF. THE BABY WAS REMOVED FROM THE DEVICE, AND AN EKG SHOWED NO EFFECTS OF THIS EVENT.