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Medical Daily
Medical Daily
Dorothy Brooks

Patients Vanished from a Hospital Monitoring System During a Software Update and Alarm Settings Reset Themselves

During a software update at one facility, some patients being monitored on GE HealthCare's Portrait Mobile devices were discharged from the monitoring system. Not discharged from the hospital. Removed from the system that was watching them.

The FDA has issued an early alert on the Portrait software, a designation the agency uses to notify the public about a potentially high-risk issue while its review continues. GE HealthCare reported a second problem alongside the first: following the update, all alarm settings may reset to factory defaults.

Together, those two failures mean a monitoring system could stop tracking a patient or keep tracking them while ignoring the alarm thresholds a clinician deliberately set for that patient or unit. The FDA says the condition can result in loss of patient monitoring or of the intended alarms at the Hub and Central Viewer.

As of the end of July, GE HealthCare had not reported any serious injuries or deaths associated with the issue.


An Update That Discharged Patients Who Were Still There

The Portrait Mobile Monitoring Solution acquires, stores, calculates, displays, and exports patient monitoring data, and provides real-time alarming for adult and pediatric patients. It is the kind of system that lets a patient move around a unit while vital signs stream back to a central station.

Four products appear in the FDA's affected list: Portrait Core Services Software versions 1.0.5 and 1.1, Portrait Compute and Core Services version 1.2, and a field-replaceable software reload for version 1.1.

GE HealthCare sent affected customers a letter on July 20 with updated use instructions. The central recommendation is short. Hospitals should ensure that appropriate alternative monitoring is in place for patients before any software update begins. The company also directs facilities to a user manual addendum with specific instructions on alternative monitoring, tells them to store that addendum with the manual, and asks that all potential users be made aware.

Notably, the FDA says the devices may continue to be used. This is a correction to how the systems are operated during updates, not a removal of the product from hospitals.


Alarm Settings Back to Factory Defaults

The alarm reset may be the more insidious of the two problems because it makes the system appear to be working.

Alarm thresholds on monitoring equipment are not arbitrary. They are configured for a patient's condition and for the care area, and a threshold appropriate for a stable adult on a general ward is not appropriate for a fragile patient elsewhere. When settings revert to factory defaults, the FDA notice states that the device will not follow the alarm settings previously configured for each patient or care area.

A monitor that shows numbers and appears operational, yet silently applies generic thresholds instead of the ones a nurse set an hour earlier, is a specific kind of hazard. Nothing looks broken.

Alarm configuration problems are a long-standing concern in hospital safety work, where the competing risks are missed alerts on one side and alarm fatigue from excessive alerts on the other. A reset to defaults can push a unit toward either failure depending on the patient, and staff may not immediately realize which way it has gone.


Software Failures Behave Differently From Broken Hardware

This alert is a useful illustration of how device risk has changed. A cracked sensor or a failed battery announces itself. A software update that quietly removes patients from a monitoring list does not, and the failure can arrive at many facilities at once the moment an update is pushed.

Maintenance is also the trigger. The hazard occurs during an update, which is precisely the activity meant to keep systems current and secure. That creates a real tension for hospital technology teams, who cannot simply defer updates indefinitely.

The remedy GE HealthCare recommends is procedural rather than technical: establish alternative monitoring before updating. That places the safeguard on hospital workflow, which means it depends on every facility receiving the letter, reading the addendum, and building the step into its update procedure. Devices already running the affected software versions remain in use for the time being.


Hospital Backup Monitoring and the Patient Side of It

For readers, the honest framing is that this is an institutional problem with no corresponding consumer action. Nobody owns a Portrait monitoring system, and no household can check anything.

What the alert does illuminate is a question that patients and families can reasonably ask when someone is hospitalized under continuous monitoring: what happens if the monitor fails? Hospitals maintain backup procedures including direct observation and manual vital sign checks, and asking a nurse how a patient is being watched is a normal question, not an accusatory one.

Families of patients on wireless or mobile monitoring may also want to understand that these systems are designed to allow movement, and that a patient walking a hallway is often still being tracked. If a monitor appears blank or silent, or if a patient's name is missing from a display, it is appropriate to tell a nurse. Staff generally welcome that.

Health care professionals and consumers can report device problems to the FDA through MedWatch. GE HealthCare is directing U.S. customers with questions to (800) 437-1171.

The FDA says it is currently reviewing information about the issue and will update its page as significant new information becomes available. Open questions include how many facilities experienced patient removals during updates, whether GE HealthCare will ship a software fix that eliminates the need for the workaround, and whether the alert escalates to a classified recall, a process the agency explains in its guide to medical device recalls. The agency maintains a running list of medical device recalls and early alerts where any change would appear.


Key Questions Answered

What went wrong?

During an update to the Portrait Core Services software at a facility, some patients monitored on Portrait Mobile devices were discharged (removed) from the monitoring system. Separately, all alarm settings may reset to factory defaults after an update.

What is an FDA early alert?

It is a notification the agency issues to inform the public about a potentially high-risk device issue while its review is still underway. The FDA updates the alert page as significant new information becomes available.

Which products are affected?

Portrait Core Services Software versions 1.0.5 and 1.1, Portrait Compute and Core Services version 1.2, and a field-replaceable software reload for version 1.1, used with Portrait Mobile Monitoring Solution devices.

Are hospitals supposed to stop using these systems?

No. The FDA states the devices may continue to be used. GE HealthCare recommends that hospitals establish appropriate alternative monitoring for patients before starting any software update, and refer to a user manual addendum for specifics.

Why does the alarm reset matter?

Alarm thresholds are configured for individual patients and specific care areas. When they revert to factory defaults, the system stops following those tailored settings while still appearing to function normally, which can mean a clinician does not receive an alert they were relying on.

Has anyone been harmed?

As of the end of July, GE HealthCare had not reported any serious injuries or deaths associated with this issue. The FDA is still reviewing information.

Is there anything patients or families should do?

Nothing at home, since these are hospital systems. Families of a hospitalized patient on continuous monitoring can ask staff how the patient is being monitored and what the backup procedure is, and should tell a nurse if a monitor appears blank or a patient's name is missing from a display.

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