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Incident · Malfunction

Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation

Two patients cared for by the same nurse had critical desaturations within seconds of one another. The monitoring system routed alarm notifications for both patients to the same Vocera badge, but the badge did not enunciate the second notification or require a separate acknowledgement. When the nurse acknowledged the first alarm, the second was automatically cancelled.

A passing staff member heard the room alarm and responded, preventing patient harm. Vocera validated the issue. The event was recreated by pulling two code blue buttons simultaneously.

Occurred 2019-04-22 · Vocera Badge · Vocera Communications · Investigated by FDA

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Incident records on DEPLOY are compiled from public sources (regulatory filings, news reports, and operator disclosures) and reflect what has been reported and tracked to date. They are not legal findings, determinations of fault, or safety ratings, and may be updated as new information is verified. See the sources below for the underlying references.
Track Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation

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Sources (1)

  1. FDA MAUDE · https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=8591239&pc=MSX · 2019-05-03

Status history

  • Active · 2026-07-30 · agent:recon

Common questions

What happened in Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation?
Two patients cared for by the same nurse had critical desaturations within seconds of one another. The monitoring system routed alarm notifications for both patients to the same Vocera badge, but the badge did not enunciate the second notification or require a separate acknowledgement. When the nurse acknowledged the first alarm, the second was automatically cancelled. A passing staff member heard the room alarm and responded, preventing patient harm. Vocera validated the issue. The event was recreated by pulling two code blue buttons simultaneously.
When did this incident occur?
The incident is recorded as occurring on April 22, 2019 on the DEPLOY registry. The date reflects the underlying real-world event, not the registry record's creation date.
What robot was involved in Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation?
Vocera Badge is the recorded robot involved in this incident.
Has anyone responded to Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation?
No responses to this incident are recorded on the DEPLOY registry. Operators, manufacturers, or affected parties can submit responses to the editorial team; absence is not a guarantee no response was issued.
What is the current status of Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation?
This incident is an active record on the DEPLOY registry; no retraction or correction has been issued.
Methodology: Unreviewed · 1 source (1 primary) · last reviewed 2026-07-30

Verification posture

Unreviewed

Low confidence

Review state

Stable

Last reviewed 2026-07-30

Sources by quality tier

1
primary-fda-database
FDA database

The framework is documented at /methodology. Corrections at /corrections. Reviewer: DEPLOY editorial team.

Methodology surface for Vocera Badge auto-acknowledged second critical alarm notification when two arrived within seconds, leaving nurse unaware of second patient's desaturation.

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Canonical ID b52058bb-f0e0-4917-944d-daf2e6a25ae3