DeathCAP
CENTRAL MONITORING SYSTEM
Received Oct 8, 1993 · Event occurred Aug 10, 1993
Report 1317346-1993-00002 · MDR key 10242
Device
Generic name
Airway Pressure Monitoring System
Manufacturer
Canadian Monaghan LimitedModel number
CM5000SCCatalog number
900-50SC-001
Lot number
P344N
Product problems
- Device Alarm System
- Disconnection
Patient
84 YR
- Death
Narrative
Description of Event or Problem
PATIENT PULLED OUT HER SHILEY TRACH WHILE CONNECTED TO A LIFE CARE LP-6 CENTRAL MONITORING SYSTEM. RESIDENT'S NURSE WALKED IN AND FOUND PATIENT TURNING BLUE. STAFF INABLE TO VENTILATE PATIENT AS WHOLE TRACH SYSTEM WAS PULLED OUT, LEAVING NOTHING TO CONNECT AMBUBAG TO. NURSE STATES ALARM WAS NOT SOUNDING ON AIRWAY PRESSURE MONITOR OR VENTLIATOR. PATIENT DIED.