Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Clinical/Biomedical Engineering; Emergency Medicine; OR / Surgery

Device Factors
*Not stated

Document Type
Checklists/Emergency Procedures

External Factors
*Not stated

Mechanism of Injury or Death
Electrical shock / electrocution; Failure to deliver therapy; Monitoring failure

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

User Checklist for Defibrillator/Monitor/Pacemakers


Date:____________ Shift:______________

Location: ________________________________________

Hospital Control No.: __________________


Model No.: __________________________

At the beginning of each shift and after each use of the device: (1) inspect the unit, (2) indicate whether all requirements have been met, (3) note any corrective actions taken, and (4) sign the form.



Corrective Actions/Remarks

1. Chassis/Housing

Ensure that it is clean, free from spills, and clear of objects on top and that its casing is intact.

2. Supplies

a. Check that the following supplies are present/within the expiration date:

(1) Monitoring electrodes.

(2) Gel or other conductive media (e.g., disposable defibrillation pads or electrodes); also, be sure they are stored properly.

(3) Pacing electrodes.*

b. Check that spare ECG paper is present.


3. Paddles (including pediatric adapters)*

a. Check that they are clean and not pitted.

b. Verify that they release from the housing easily.

c. If internal paddles are included, verify that they are available in a sterile package.


4. Cables/Connectors

a. Inspect for cracks or damage.

b. Verify that connectors are engaged securely.


5. Power Supply

a. Verify that the unit or charger is plugged into a live outlet and that AC power and/or battery-charging indicators are on.

b. For units with user-replaceable batteries:

(1) Verify that a fully charged battery (or a full complement of batteries for units that accept or require more than one) is in place.

(2) Ensure that a spare charged battery is available.

(3) Follow an appropriate battery rotation schedule per the manufacturer's recommendations.


6. Indicators/ECG Display

a. Turn the unit on, and verify that it passes the self-test.*

b. Verify that the monitor display is functional.

c. Check that the "Service" message display is off.*


7. ECG Recorder

a. Check that the unit has sufficient ECG paper.

b. Verify that the recorder prints.

c. Verify that the time/date agrees with the dispatch center.


8. Pacemaker*

a. Inspect according to the manufacturer's operational guidelines.

b. Verify output from the pacing cable.**


9. Charge/Discharge Cycle for Paddles or Defibrillation Electrode Cable**

a. Disconnect from line power to allow battery-powered operation.

b. Charge to the manufacturer's recommended test energy level (or 50 J).

c. Verify that charge indicators are working.

d. Discharge into an appropriate test load to verify adequate output.

e. Verify that the low-battery indicator is still off.


10. Reconnect to Line Power


Problem(s) identified. Contacted:_____________


Work Order No.: ___________________________

Phone extension for Clinical Engineering Dept.: _________________

* Applicable only if the unit has this accessory or capability.

**The frequency with which these operational checks are performed (e.g., daily, weekly) should be determined by the healthcare facility with consideration of the manufacturer's recommended interval for output testing.

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