The electronic logfile was available for investigation.The reported event could be reconstructed by means of the information stored therein.During the case in question, the primus detected that the vacuum pressure went out of range.As per specification, the device forced a shutdown of automatic ventilation and posted the corresponding vent fail alarm.The log indicates that the user completed the procedure in manual ventilation.It can be concluded that a failure of the pressure sensor that monitors the auxiliary vacuum pressure has caused the system response.Dräger finally concludes that the device reacted as designed.No patient consequences have occurred; the number of similar cases, related to the same root cause, is within the expected range of the respective risk assessment and thus accepted.
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