Description of Event or Problem · 1
ICU NURSE REPORTED THE FOLLOWING: 0300: THE CENTRAL MONITORING SCREEN WENT BLACK WITH NO DISPLAY. IT STILL HAD POWER AND, WHILE TROUBLESHOOTING THE SYSTEM, A SCREEN APPEARED STATING NO SIGNAL INPUT. NURSE CHECKED THE INCOMING CABLES AND THERE WERE NO DISCONNECTED CABLES. THE ONLY THING THAT WAS SHOWING WAS THE ROOM NUMBERS ON THE MONITOR SCREEN. AT 0305: NURSING SUPERVISOR ARRIVED IN UNIT AND STATED THE MED/SUR MONITOR ALSO LOST ITS DISPLAY. AT 0310: PHILIPS TECH SUPPORT NUMBER CALLED. PHILIPS OPERATOR STATED THE TECH WILL BE CALLING SHORTLY. AT 0330: PHILIPS TECHNICIAN RETURNED CALL, WAS UPDATED BY ICU NURSE AND REQUESTED THAT A BIO-MED PERSON LOOK AT THE SYSTEM BELIEVING IT WAS PROBABLY A PROBLEM WITH THE COMPUTER TOWER SERVICING THE MONITOR OR A CABLE FAILURE IN THE SYSTEM. AT 0340: NURSING SUPERVISOR PAGED INFORMATION SYSTEMS (IS). THEY CALLED RIGHT BACK AND ADVISED NURSING TO CALL ANOTHER IS TECHNICIAN BECAUSE HE WAS THE BEST OPTION FOR FIXING THIS PROBLEM. THE IS TECHNICIAN WAS PAGED BY THE NURSING SUPERVISOR. AT 0345: IS CALLED AND ASKED THE NURSE TO ATTEMPT TO RESOLVE THE PROBLEM BY CHECKING VARIOUS CABLES AND UNPLUGGING SOME POWER CORDS TO NO AVAIL. IS RELAYED THAT HE WILL BE COMING TO THE HOSPITAL. AT 0425: IS ARRIVED IN THE ICU AND BEGAN TO TROUBLESHOOT THE SYSTEM. AT 0433: CENTRAL MONITOR BACK ON LINE AND FUNCTIONING AS IT SHOULD. PROBLEM: IS FOUND A POWER SUPPLY MODULE BEHIND THE MONITOR THAT LOOKED SUSPICIOUS WITH MELTED AND DEFORMED HOUSING. IS TOOK THE EQUIPMENT INFORMATION AND CASE NUMBER SAYING HE WAS GOING TO CALL THE PHILIPS TECHNICIAN AND ADVISE HER OF WHAT HE FOUND. THE MED/SUR MONITOR CAME BACK ON LINE AT THE SAME TIME THE ICU MONITOR DID. A NEW POWER SOURCE WAS ORDER TO BE DELIVERED OVERNIGHT. IN THE MEANTIME, IS PROVIDED A TEMPORARY POWER SOURCE. DISCUSSION- PLEASE NOTE: THIS IS ONE OF THREE SIMILAR FAILURES OF MONITORS SECONDARY TO FAILURE OF THE SAME MODEL POWER SUPPLY DURING THE PAST 8 WEEKS. POWER SUPPLIES ARE ORIGINAL POWER SUPPLIES PURCHASED FROM PHILIPS AS PART OF THE MONITOR INSTALLATION. TWO OF THESE FAILURES HAPPENED TODAY. NO ADVERSE PATIENT EVENT AROSE. HOWEVER, LOSS OF PATIENT MONITORING ENDANGERED PATIENT SAFETY. THE POWER SUPPLY OVERHEATING TO THE EXTENT OF MELTING AND CHARRING THE PLASTIC HOUSING AND THE LABEL SUGGESTS A FIRE HAZARD THAT COULD ENDANGER THE SAFETY OF MULTIPLE PATIENTS, HEALTH CARE WORKERS AND VISITORS. PHOTOS OF THE DEFECTIVE POWER SUPPLY WILL BE SENT VIA E-MAIL. THERE IS NO SUGGESTION OF POWER PROBLEMS IN THE BUILDING. NO RECORDED BLACK OUTS OR "BROWN-OUT" (POWER DROPS) DURING THIS TIME FRAME. PHILIPS' INITIAL RESPONSE WAS TO ATTRIBUTE THIS TO COMMERCIAL POWER PROBLEMS. THESE ARE THE ONLY THREE DEVICES IN THE BUILDING EXPERIENCING PROBLEMS - WITH THOUSANDS OF OTHER ELECTRICAL / ELECTRONIC DEVICES IN USE. THESE POWER SUPPLIES ARE NOT PHILIPS INTERNALLY MANUFACTURED PRODUCT. THEY ARE PRODUCED BY GLOBTEK, INC. MANUFACTURER RESPONSE FOR PATIENT MONITOR - POWER SUPPLY, PHILIPS (PER SITE REPORTER): PHILIPS IS SENDING THREE REPLACEMENT POWER SUPPLIES. WE HAVE HAD FAILURE OF THREE OF THESE DEVICES IN THE PAST 8 WEEKS. WE HAVE NOT OBSERVED ANY OTHER DEVICES IN THE BUILDING HAVING SIMILAR PROBLEMS - OR ANY OTHER SHOWING SIGNS SUGGESTIVE OF PROBLEMS WITH COMMERCIAL POWER.