INVOS

Description of Event or Problem

FOLLOWING IMPLEMENTATION OF THE UPDATED NIRS SYSTEM, STAFF HAVE REPORTED PERSISTENT SENSOR ADHESION FAILURES WITH THE NEW ACRYLIC-BASED PEDIATRIC AND ADULT SENSORS, INCLUDING FREQUENT DETACHMENT FROM THE PATIENT¿S SKIN AND INCONSISTENT SIGNAL ACQUISITION DESPITE ADHERENCE TO UPDATED APPLICATION GUIDANCE (SKIN PREP, PRE-WARMING, AND SECURING TECHNIQUES). THESE ISSUES HAVE BEEN OBSERVED ACROSS MULTIPLE UNITS EVEN AFTER VENDOR-SUPPORTED EDUCATION.