LIFEPAK Incident Report
Use this form to document Lifepak malfunctions, errors and issues.
OCA#
If incident occurs during patient care please list the OCA
Monitor #
*
Please Select
LP1 - 51464755
LP2 - 51500087
LP3 - 51464712
LP4 - 51500012
LP5 - 51499198
LP6 - 51471870
LP15 1 - 49376768
LP15 2 - 49377308
LP15 3 - 49377417
LP15 4 - 49377768
LP15 5 - 49377785
LP15 6 - 49377474
LP15 7 - 49376830
LP15 8 - 49376650
Name of person submitting IR
*
Type of Issue Observed
*
SpO₂ / Pulse Oximetry
ECG / Rhythm Monitoring
12-Lead ECG Acquisition / Interpretation
NIBP (Blood Pressure)
Defibrillation / Pacing
Power / Battery / Charging
Touchscreen / User Interface
Software Freeze / Reboot Required
Alarms (missing, delayed, or incorrect)
Cables / Connectors / Ports
Audio / Speaker / Volume
Data Transmission / Wi-Fi / Upload
Other
Detailed description of issue:
*
If Blood Pressure was inaccurate please document manual BP findings here:
Troubleshooting Performed:
*
Power cycle / reboot
Cable reseated
Cable replaced
Sensor replaced
Accessory moved to different port
Device self-test performed
Issue resolved temporarily
Issue did NOT resolve
No troubleshooting attempted
Other
Patient Care & Impact
Was the device in active patient care?
*
Yes
No
Impact on Patient Care
*
No impact
Required alternate equipment
Increased time on scene
Delayed treatment
Clinical decisions made without device data
Patient Harm
None
Potential (no injury)
Actual
Photo Upload
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Upload:Photos or videos of the malfunction to include monitor screenshots if needed
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