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Faulty Design Resulting in Temporary Pacemaker Failure*

Bruce Kleinman, MD; Margaret Baumann, MD; Charles Andrus, MD
Author and Funding Information

*From the Anesthesia Service (Dr. Kleinman), the Department of Medicine (Dr. Baumann), and Department of Surgery (Dr. Andrus), Edward Hines Jr. Veterans Hospital, Hines, IL.

Correspondence to: Bruce Kleinman, MD, Chief, Anesthesia Service-112A, Edward Hines Jr. Veterans Hospital, PO Box 5000, Hines, IL 60141; e-mail: bkleinm@luc.edu



Chest. 2001;120(2):684-685. doi:10.1378/chest.120.2.684
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A 77-year-old man became asystolic 3 days after aortic valve replacement and coronary artery bypass surgery. A dual-chamber temporary pacemaker generator was turned on but failed to discharge; instead, an obscure error message appeared on the liquid crystal display of the pacemaker. The intensive-care nurses and physicians were unable to activate the pacemaker. We describe the pacemaker design that led to this instance of pacemaker failure. This case is important because it illustrates how a medical equipment design flaw can turn a human error into a potentially catastrophic event.


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