FDA Adverse Event Malfunction Summary report: N

ABL800 FLEX WITH FLEXQ MODULE

MDR report key: 1023678 · Received April 1, 2008

Report

Report Number
3002807968-2008-00007
Event Type
Malfunction
Date Received
April 1, 2008
Date of Event
March 2, 2008
Report Date
March 3, 2008
Manufacturer
RADIOMETER MEDICAL APS
Product Code
CHL
PMA / PMN Number
K043218
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
SW
Reporter Occupation
PHYSICIAN

Narratives

Additional Manufacturer Narrative · 1

INVESTIGATION ONGOING TO DETERMINE ROOT CAUSE.

Description of Event or Problem · 1

BLOOD GAS ANALYZER MEASUREMENTS ON AN ABL827 BLOOD GAS ANALYZER HAVE RESULTED IN MIX-UP OF PT ID DUE TO UNINTENDED REPEATED BARCODE READING OF THE SAMPLER PLACED IN THE FLEXQ TRAY SLOT 1. THE SAMPLER IN SLOT 1 WAS INCORRECTLY POSITIONED. WHEN ENTERING NEW SAMPLERS IN SLOT 2 AND 3, AND THEREBY INITIATING BARCODE READING OF THEIR PT ID, THE SAMPLER IN SLOT 1 WAS BLOCKING THE BARCODE READING. INSTEAD THE SOFTWARE ALLOWED THE BARCODE READER TO RE-SCAN THE BARCODE OF THE SAMPLER IN SLOT 1.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 ABL800 FLEX WITH FLEXQ MODULE BLOOD GAS ANALYZER CHL RADIOMETER MEDICAL APS ABL827

Patients

Seq Age Sex Outcome Treatment
1