Earlier this year, a bunnell instruments ventilator stopped working while in use.No patient harm was reported as a respiratory therapist was able to manually support the patient.The unit stopped venting after being operating normally for a couple of days.A sudden ventilator fault alarm went off, causing the unit to go into standby and dashes were displayed on the display panel.Rt at bedside turned the ventilator off and back on, ran through self test which ventilator passed.Unit was replaced by another ventilator to be able to properly conduct an incident investigation.Unit was check with manufacturer and were able to reproduced the same problem.It was found that an intermittent servo pressure transducer would cause a false servo pressure display of 19.6 psi which would cause the system to generate random loss of pip, cannot meet pip and vent fault 10 alarms which would cause the vent to stop venting.The servo pressure transducer was replaced which restored system stability and a complete system calibration was performed with no drift over time observed.
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