It was reported to epocal on 28-mar-2017 (case number (b)(4)) that the epoc host (hh-1r09-00-00) with s/n (b)(4) froze during testing on a patient experiencing a code blue medical emergency.The patient was declared deceased.The initial reporter stated: "the epoc host failure caused: failure in proper patient care.The doctor needed blood gas results quick and after the blood was in machine, respiratory therapy, the doctor and nurses were all waiting for results.After blood was done the machine froze up and i was unable to get results nor input any information in on the patients or what tests i wanted.I had to grab another machine which took extra time that we do not have during a code blue.The machine that i grabbed from icu worked very good and quick, per the phlebotomist." the patient a (b)(6) in-patient male experienced a code blue medical emergency, which began at approximately 19:36 on (b)(6) 2017.The patient had a medical history/diagnosis of: "acute on chronic systolic heart failure with ejection fraction 35%, cardiac shock, acute hypoxic respiratory failure due to previous listed." cpr was performed for approximately 40 minutes and the patient was declared deceased at 20:41 on (b)(6) 2017.The cause of death was "polymorphic ventricular tachycardia.Patient went in to asystole".Clarification on the initial statement: "the epoc host failure caused: failure in proper patient care", was requested.The customer responded on 06-apr-2017, stating what she thinks the phlebotomist meant: "the phlebotomist was not able to give results to the doctor when he wanted them.However, cpr was in progress".The epoc host (hh-1r09-00-00) with s/n (b)(4) is expected to be returned for manufacturer investigation.The investigation is underway.An internal medical review determined that in a situation where a patient with known chf suffers cardiac arrest due to polymorphic ventricular tachycardia, there is no role for blood gas or laboratory results.As such, there is no information to suggest that the delay in receiving a result due to the frozen epoc caused or contributed to the patient death.However, the event is being conservatively reported based on the statement provided by the customer and the limited clinical information available in the case.
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