Ge healthcare¿s investigation found that a number of carescape t14 transmitters at the site were generating the telemetry interference.
The transmitters were found stored with the batteries engaged and actively discharging.
When the returned transmitters were examined the issue could be reproduced while attempting to ¿power on¿ the transmitters in a number of cases.
The design of the transmitter does not include an ¿on/off¿ switch.
When the battery door is closed and there is sufficient voltage present, the transmitter will attempt to power on.
The interference caused by the transmitters was the result of the transmitters being stored with the batteries installed.
The product labeling includes info about storage of the transmitters when not in use monitoring pts and cautions the user about using old batteries as this can compromise the functionality of the transmitter.
The product labeling also recommends to replace the batteries of the transmitter promptly when the change of battery notification occurs at the central station to avoid a loss of monitoring.
Ge healthcare informed the hosp of the need to change batteries promptly when the ¿change battery¿ condition is asserted, as well as not storing the transmitters with the batteries installed.
It was reported that telemetry monitoring was lost on 14 pts for up to 5 mins as a result of interference.
The issue seemed to resolve itself before the source of the interference could be determined.
The biomed recorded the interference on a spectrum analyzer and, based on previous experience, believed the issue was likely due to a telemetry box problem.
There was no serious injury or death associated with this event, nor was medical intervention required.