title: A widely unappreciated cause of failure of an automatic noninvasive blood pressure monitor.
abstract: Many anesthesiologists have come to depend on automatic noninvasive blood pressure monitoring to obtain blood pressure (BP) readings. A case is presented in which, during a critical phase of the anesthetic, an automatic noninvasive blood pressure (ANIBP) device not only failed to provide meaningful clinical data but, in fact, gave an error message that was misleading. At the time of the message, the patient was noted to be in ventricular trigeminy at a rate of 92 beats/min. It appears that the repetitive beat-to-beat fall in blood pressure due to the dysrhythmia "fooled" the automatic noninvasive blood pressure device's software algorithm into believing that there was an air leak in the system. Thus, in addition to pointing out an unappreciated and potentially troubling device-related critical event, the present case demonstrates the importance of good human factors design for medical devices used in the critical care setting. In particular, the issue is raised of how medical devices should deal with uncertain or potentially misleading data.
authors.affiliation: Department of Anesthesiology, San Diego VA Medical Center, CA 92160.
authors.forename: M B
authors.initials: MB
authors.lastname: Weinger
authors.forename: T S
authors.initials: TS
authors.lastname: Scanlon
authors.forename: L
authors.initials: L
authors.lastname: Miller
mesh_terms: D000368:Aged; D001794:Blood Pressure; D015924:Blood Pressure Monitors; D004562:Electrocardiography / Q000295:instrumentation; D004867:Equipment Design; D004868:Equipment Failure; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis*; D008297:Male; D016343:Monitoring, Intraoperative / Q000295:instrumentation*; D012815:Signal Processing, Computer-Assisted / Q000295:instrumentation*; D017180:Tachycardia, Ventricular / Q000175:diagnosis*