Maladjustment of programmable ventricular shunt valves by inadvertent exposure to a common hospital device

BACKGROUND: Programmable ventricular shunt valves are commonly used to treat hydrocephalus. They can be adjusted to allow for varying amounts of cerebrospinal fluid (CSF) flow using an external magnetic programming device, and are susceptible to maladjustment from inadvertent exposure to magnetic fields. CASE DESCRIPTION: We describe the case of a 3-month-old girl treated for hydrocephalus with a programmable Strata(TM) II valve found at the incorrect setting on multiple occasions during her hospitalization despite frequent reprogramming and surveillance. We found that the Vocera badge, a common hands-free wireless communication system worn by our nursing staff, had a strong enough magnetic field to unintentionally change the shunt setting. The device is worn on the chest bringing it into close proximity to the shunt valve when care providers hold the baby, resulting in the maladjustment. CONCLUSION: Some commonly used medical devices have a magnetic field strong enough to alter programmable shunt valve settings. Here, we report that the magnetic field from the Vocera hands-free wireless communication system, combined with the worn position, results in shunt maladjustment for the Strata(TM) II valve. Healthcare facilities using the Vocera badges need to put protocols in place and properly educate staff members to ensure the safety of patients with Strata(TM) II valves.