Implantable Cardioverter Defibrillator Clinic Casualties: Inadvertent Reprogramming During Routine Implantable Cardioverter Defibrillator Follow-Up

On one occasion during a busy ICD follow-up clinic, the preceding patient's parameters for rate, PDF, and delay were inadvertently programmed into the subsequent patient's generator using the CPIProgrammer Model 2035. This occurred after capacitor reformation, without pressing the "Program" button. The source of this reprogramming error was failure to clear the programmer memory of the previous patient's data, usually achieved by turning the programmer off between patients (or selecting "New Patient" from the menu). At our next ICD follow-up clinic, we purposely did not turn off the programmer between two sets of patients. On both occasions the above finding was repeated and confirmed. These observations indicate the potential for serious reprogramming errors that can occur simply by not clearing the programmer's memory between clinic patients.