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It was reported the monitor did not alarm appropriately for hypotension.The patient's noninvasive blood pressure was recorded as 43/37, and a yellow alarm occurred but no red alarm; therefore, the patient's deterioration went unnoticed in the icu.The customer requested assistance in determining why there was no red alarm generated.It was noted the systolic alarm limit was 160 and systolic low was 100.The following was stated by the customer, "this patient was being cared for by a new grad nurse, who actually left the patient to talk to a doctor ¿ not recognizing that this was an emergency and she should have stayed with the patient.Fortunately, there were 2 very senior nurses at the nurse's station who saw the number on the central monitor and went to check on the patient, who was alone and symptomatic in relation to the very low bp.This is a near miss rather than an adverse outcome ¿ however, this scenario could easily re-occur where no one is standing at the monitor observing this, or where its taken automatically and there¿s no nurse in the room, the current tone would not necessarily attract urgent attention and a patient could have an adverse outcome related to this".It was also noted that yellow alarms are noticed but not always immediately resolved or responded to in this care unit.The patient required temporary inotropic medication support with small fluid boluses but there were no adverse effects to the patient noted.The incident was noted to be a near miss as the more senior nurses noted the change in patient condition.There was no evaluation of the device as the device behaved as specified but the lack of red alarms was unexpected for the customer.
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