The nursing director reported via the customer's biomed that a newborn in room 15 of the picu that was post cardiac surgery had a hr of 49 beats per minute (bpm) on (b)(6) 2019 around 23.43.As a result, the nurse started cpr.The attending physician stopped cpr after 45 seconds, noting that the pulse rate was 90 and that the intellivue mp70 was undercounting the baby's paced beats.The biomed collected the ecg strip report for the reported event which was forwarded to a philips remote application specialist (ras) for evaluation.During the evaluation of the strip report, it was revealed that pacing detection was switched on.A tic mark on the strip and the letter "p" ("paced") indicated the paced beats.Several heart beats were not labeled, meaning that they were missed and were not being counted, which was the reason for the low heart rate numeric.The monitor was not tested as this occurrence was identified as a clinical application issue.The investigation results were provided to the nursing director by email.Additionally, the st/ar algorithm application note was provided to the customer for further reference.No further calls from the customer were logged regarding the reported device and issue.The monitor remains at the customer site.The device worked as intended and there was no malfunction of the monitor.This issue was caused by user error.No further investigation or action is warranted.
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