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Model Number N1, NELLCOR, ST, GLASGOW |
Device Problem
Mechanical Problem (1384)
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Patient Problems
Head Injury (1879); Laceration(s) (1946)
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Event Date 09/13/2023 |
Event Type
Injury
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Manufacturer Narrative
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The investigation determined that the n1 was not securely seated (latched on) into the mount, causing it to fall out.The hospital concluded that it was a user error.Mindray field service evaluated the benevision n1 and the locking mechanism and no issues were identified.The benevision n1 patient monitor operator's manual provides instructions on ensuring that an n1 is correctly latched in the dock and cannot be pulled out.The user must firmly push the n1 until an audible click is heard, indicating that the clip engaged the dock.
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Event Description
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It was reported that on (b)(6) 2023, at 9:30 am an benevision n1 patient monitor (serial number (b)(6)) had fallen off its dock and struck a patient's head.The patient suffered a laceration upon impact.A ct scan was performed on the patient, and the scan came back normal.
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Search Alerts/Recalls
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