DeathCAP
VENTIALARM II
Received Mar 31, 1999 · Event occurred Feb 19, 1999
Report 221768 · MDR key 221768
Device
Generic name
External Ventilator Alarm
Manufacturer
Hudson RciModel number
5622Catalog number
NA
Lot number
NA
Product problems
- Failure, intermittent
Patient
82 YR
- Cardiopulmonary Arrest
- Cyanosis
- Death
- Resuscitation
- Manual ventilation required
Narrative
Description of Event or Problem
AT 12:50 PM RN CHARGE NURSE ENTERED PT'S ROOM. PT WAS DUSKY IN COLOR AND WITHOUT VITAL SIGNS. VENTILATOR AND ALARMS NOT SOUNDING. VENTILATOR CIRCUIT OBSERVED TO BE DISCONNECTED FROM TRACH, VENTILATOR PRODUCING AIR HOWEVER PRESSURE ALARM DID NOT SOUND. CIRCUIT RECONNECTED TO TRACH, THEN REMOVED TO INITIATE MANUAL VENTILATION AND CPR. AFTER CIRCUIT DISCONNECTED FOR CPR ALARMS SOUNDED IN APPROX 5 SECONDS.