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Analysis was performed by philips remote clinical support (rcs), who spoke to the customer.The audit logs revealed red technical inop alarms for ecg leads off occurred at 2222 and were acknowledged at 2225.The alarm reminders occurred approximately every 3 minutes until 2352.The patient coded at approximately 2330 and passed away.The manager requested assistance reviewing events leading up to the patient code.It was further indicated there were multiple admissions doing on at the time of the event.The audit log review revealed the user had not signed into the phone, so al alarms for telemetry were being sent to the phone and dropped due to this.The primary nurse eventually responded to the red technical inop alarms, but her phone was not receiving notifications due to the aforementioned sign in issue.In addition, it was noted there was no staff at the central station at this time.Based on the results of the analysis, the device was confirmed to be operating per specifications and no failure was identified.Philips senior clinical solution consultant went onsite and worked with the nurse manager.Showed the nurse manager how to use the audit logs at the pic.We were able to see that a red ¿leads off¿ alarm was announced at the pic, as well as several re-alarms (reminders).I also discussed with her ways to improve ecg signal on a patient (applying electrodes in the correct position, implementing good skin prep, changing electrodes at least every 24 hours, etc.).A review of the service history for this device shows there have been no additional issues reported related to this device.
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