Description of Event or Problem · 1
MOTHER WAS IN LABOR, WITH NORMAL PROGRESSIONS FOR BOTH THE MOM AND NEONATE. THE CERNER FETALINS SYSTEM WENT DOWN AFTER POWER SURGE WITH A < 1 SECOND OUTAGE. AFTER THE SYSTEM WENT DOWN, A REGISTERED NURSE (RN) WAS ASSIGNED FULL-TIME TO THE ROOM. NEWBORN ENTERED A DISTRESSED STATE, THE RN SHOUTED FOR ASSISTANCE AND A DOCTOR WAS CALLED. STAFF SPEAKING WITH DOCTOR WAS NOT ABLE TO GIVE FULL INFORMATION FROM THE NURSES STATION AS THE CENTRAL MONITOR WAS DOWN. THE DOCTOR RESPONDED AND STARTED THE DELIVERY. FULL INFO WAS NOT AVAILABLE DURING THE DELIVERY AS THE VIEW OF THE FETAL MONITOR WAS BLOCKED BY STAFF WORKING WITH THE PATIENT. DELIVERY WAS ACCOMPLISHED SUCCESSFULLY, WITH AN APGAR OF 8/9 BECAUSE THE INFANT WAS NOTED TO HAVE A BROKEN CLAVICAL INCIDENTAL TO THE DELIVERY. THIS IS SUBMITTED AS A POTENTIAL NEAR MISS IF STAFFING DID NOT ALLOW A RN FULL TIME IN THE ROOM AFTER THE FAILURE OF THE MONITORING SYSTEM, AN ADVERSE EVENT MAY HAVE OCCURRED. THE PROBLEM WITH THE SYSTEM WAS THE POWER FAILURE CHANGED THE TIME ON ONE OF THE CERNER DEVICES TO OUTSIDE THE +/- 30 SECOND WINDOW PERMITTED. IT RESOLVED THE ISSUE IN APPROXIMATELY 2 HOURS (EASY FIX, TROUBLESHOOTING TOOK SOME TIME) USING A COLLABORATIVE TEAM, CERNER, CORPORATE IT, INFORMATICS, BIOMEDICAL STAFF. MANUFACTURER IS INVOLVED IN RESOLUTION OF THE PROBLEM. AS STATED ABOVE THIS IS A HEADS-UP REGARDING TECHNOLOGY FAILURE AND THE POTENTIAL FOR SIGNIFICANT PATIENT HARM. OUTCOME ON THIS PROCEDURE WAS NOT SIGNIFICANTLY CHANGED BY THE FAILURE OF THE EQUIPMENT.