_Incident · Malfunction_

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

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

- **Occurred:** 2019-04-22
- **Kind:** `malfunction`
- **Status (derived):** active
- **Model:** [Vocera Badge](/models/vocera-badge.md) (id: `7dfdb7e9-be06-4c56-a06e-674f45d0f970`)
- **Company:** [Vocera Communications](/companies/vocera-communications.md)

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](/models/vocera-badge.md), 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.

## 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.


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