| Model Number |
BENEVISION N12 |
| Medical Device Problem Code |
Device Alarm System (1012)
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| Health Effect - Clinical Code |
Insufficient Information (4580)
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| Date of Event |
10/10/2025
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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The benevision n12 patient monitor (serial number: (b)(6) was being used with an mpm (serial number: (b)(6).Mindray tested the units involved and could not duplicate the issue.Logs data from the monitor, central station, and patient database were collected and reviewed.It was determined that the heart rate calculation function operated per device specifications, the incident did not meet the requirements to trigger a v-tach alarm.No malfunction was identified.Upon receipt of medwatch report # mw5177989, mindray made good faith efforts to obtain additional details from the facility to clarify the rationale for classifying the occurrence as "required intervention" and "serious injury." no further information was provided, and no patient injury was confirmed.
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Event or Problem Description
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Per medwatch report reference # mw5177989: nurse was going through event logs to print off a strip from the patient's records.While going through the records, a run of premature ventricular complexes (pvcs) were found at a tachycardic rate and there was no highlighting of that trace to indicate any alarms.There was also no change in calculated heart rate.There were no alarms that sounded at the time of event.From the attached image of the strip, it is evident that there was a ventricular tachycardia (v-tach) event.After this was found, staff got biomed involved to do an investigation.From biomed's findings, the multiparameter module (mpm) module that was in the nemesis prime (n12) monitor was unable to annotate the qrs complex.The compatibility issue is believed to be why there was no alarm.Meanwhile, the patient was moved to a different room with a new n12 and n1 module connected and there was a v-tach alarm for a similar run of pvcs.Mindray was called and created an investigation of their own.Their initial findings were that the monitor was correct in its calculations and the waveform from the incident did not meet the requirements to trigger a v-tach alarm.There has not been any mention of the mpm not being compatible with the n12 monitor.This voluntary report is being submitted primarily so that other hospitals with mindray n-series monitors and mpm modules can be made aware of this event.
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Search Alerts/Recalls
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