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Background: Although electromagnetic interference (EMI) with medical equipment is described in the engineering community, little documentation exists in the medical literature to address this largely theoretical concern. The FDA collects data on EMI, but often faces resistance from health care facilities during their investigations. Case Report: An 18-year-old male with metastatic chondrosarcoma, who was receiving an epinephrine infusion for septic shock, developed acute onset of agitation, hematemesis, and chest pain nine hours after the infusion began. Physicians diagnosed acute epinephrine poisoning and noted that the infusion bag contained less than the expected volume. Calculations determined that the patient received 10.5 mg of unintended epinephrine. The infusion pump was turned off and, despite myocardial ischemia and pulmonary edema, the patient ultimately recovered with supportive care. Examination of the implicated infusion pump found it was in normal working condition. Further scene investigation noted that a cellular phone in 'standby mode' as present in the immediate area during the event. When exposed to a similar 'standby' cellular phone in a laboratory setting, the infusion pump reproduced its bolus delivery. During the event the pump displayed '999' mL/h and corrected to the previous setting upon cessation of the signal. Interrogation of the pump's memory revealed that it did not record this event. The investigators thereby concluded the EMI was responsible for the infusion pump failure. Conclusions: This is the first documented case in which EMI with sensitive medical equipment caused substantial human morbidity. The implications of this interference are potentially grave and the health care industry should be cognizant of such possibilities. Reporting of all potential EMI events to the FDA and assistance in their inquiry is suggested., Hahn I, Schnadower D, Dakin RJ, Hoffman RS, Nelson LS. New York City Poison Control Center, New York University, New York, [...]