Clinical risk – Cardiac Arrest

The Problem

A patient was brought to hospital having suffered a cardiac arrest. Fortunately, it occurred in public, and he was resuscitated. He was dependent on pacing from a defibrillator, but the lead had failed. Investigation showed that he had a Sprint Fidelis lead, known to have a high risk of failure, and long subject to a Medical Device Alert (MDA). The hospital had, some years earlier, contacted all patients under their care with these leads to download new software to their device, and intensify follow up, including remote monitoring of their leads.

However, as they were using an inadequate database at the time, this patient was entirely overlooked and was only under annual hospital follow up. This error had very nearly led to the patient’s death, and had resulted in severe injury.

The response

The PACENET database carries comprehensive details of implanted hardware in all patients, including whether or not it is currently connected, and whether the patient is pacing dependent. The database can easily be searched across multiple parameters to identify patients of interest. It also has an integral and dedicated MDA management system designed to prevent errors of this kind ever occurring and to allow a hospital to demonstrate that an effective management plan for MDAs has been created and followed through.