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Philips received a complaint on a patient information center ix indicating the customer requested assistance obtaining information following the death of a telemetry patient.The clinical audit log was reviewed, revealing red alarms including asystole were generated prior to the ecg leadset becoming unplugged at 0925.After this, there was an ecg leads off alarm, an alarm pause, atrial fibrillation alarm then ended.The alarms were acknowledged at the surveillance, after which time there was no further information seen from this patient until 1905 when a tele battery low technical alarm was generated.The nurse indicated the patient was found unresponsive and pulseless sometime after 1800.Though the exact cause of the event remains unknown, the customer stated, 'they are not reporting that the issue was caused by the device and believe the issue was probably caused by nurses not replacing the tele pack batteries after receiving low battery notifications requiring replacement to continue monitoring'.Based on the information received, there does not appear to be a device malfunction that caused or contributed to the reported death; however, use issues related to alarm management and clinical workflow may have been factors.
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Analysis was performed by onsite service personnel which included pulling the alarm logs and communication with the customer.The results of the analysis confirmed there was no issue with the philips equipment.Based on the results of the analysis, the product was confirmed to be operating per specifications and use issues related to alarm management and clinical workflow may have been factors in the event.The customer was provided with alarm logs as requested.Based on the information available and results of additional analysis, no further action is necessary at this time.If additional information is received, the complaint file will be reopened for further investigation.
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