MalfunctionFLL
LEVEL 1 ESOPHAGEAL / RECTAL 9F
Received Apr 17, 2025 · Event occurred Apr 9, 2025
Report 21852897 · MDR key 21852897
Device
Generic name
Thermometer, Electronic, Clinical
Manufacturer
Smiths Medical Asd, Inc.Model number
ER400-9Catalog number
ER400-9
Product problems
- Incorrect, Inadequate or Imprecise Result or Readings
Patient
5 MO · Male
- Arrhythmia
- Fever
- Arrhythmia
- Fever
Narrative
Description of Event or Problem
A RECTAL TEMP PROBE HAD BEEN PLACED FOR PATIENT FROM THE OR. THE NURSE (RN) CHECKED IT, PUSHED IT IN FURTHER, WAS READING 34-36C. THROUGH THE NIGHT, THE PATIENT HAD INCREASING ARRHYTHMIA. TEMP CHECKS ON THE RECTAL PROBE CONTINUED TO READ AFEBRILE DESPITE GOOD POSITIONING. RN REPLACED PROBE AND TEMP READ 38.2C. ESOPHAGEAL PROBE PLACED AND READ 40.2C. AN UNDETECTED FEVER CONTRIBUTED TO A BAD ARRHYTHMIA THAT COULD HAVE CAUSED HEMODYNAMIC INSTABILITY IN A TENUOUS CARDIAC POST OP PATIENT. ORIGINAL TEMP PROBE WAS FAULTY.