BEUDAMED
    FDA Adverse Event Injury Summary report: N

    NXSTAGE SYSTEM ONE

    MDR report key: 1040589 · Received May 9, 2008

    Report

    Report Number
    3003464075-2008-00198
    Event Type
    Injury
    Date Received
    May 9, 2008
    Date of Event
    April 12, 2008
    Report Date
    April 12, 2008
    Manufacturer
    NXSTAGE MEDICAL, INC.
    Product Code
    KDI
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THE REPORTED BLOOD LOSS IS ATTRIBUTED TO USER ERROR AS THE OPERATOR FAILED TO MAKE THE PROPER CONNECTIONS FOR RINSEBACK. THE USER'S GUIDE PROVIDES ADEQUATE INSTRUCTIONS FOR PATIENT CONNECTIONS AND PERFORMING RINSEBACK. FACILITY STAFF ATTRIBUTED THE ALARMS TO A NARROWING OF THE PATIENT'S ACCESS WHICH HAS SINCE BEEN RESOLVED. A DIRECT CORRELATION BETWEEN NXSTAGE SYSTEM ONE AND THE REPORTED BLOOD LOSS CANNOT BE ESTABLISHED. NXSTAGE MEDICAL CONSIDERS THIS REPORT CLOSED. NO ADDITIONAL INFORMATION WILL BE PROVIDED.

    Description of Event or Problem · 1

    THIS REPORT IS BEING FILED AS AN ADVERSE EVENT SOLELY TO COMPLY WITH THE FDA'S BLOOD LOSS POLICY. VENOUS PRESSURE LOW ALARMS OCCURRED DURING A ROUTINE HEMODIALYSIS TREATMENT, WHICH COULD NOT BE RESOLVED. WHILE ATTEMPTING TO CONNECT FOR RINSEBACK, THE OPERATOR INADVERTENTLY LEFT THE ACCESS LINE CLAMPED. RINSEBACK WAS NOT PERFORMED DUE TO CLOTTING RESULTING IN AN ESTIMATED BLOOD LOSS OF 190CC. NO MEDICAL INTERVENTION WAS REQUIRED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 NXSTAGE SYSTEM ONE HIGH PERMEABILITY HEMODIALYSIS SYSTEM KDI NXSTAGE MEDICAL, INC. CAR-170 8017710

    Patients

    Seq Age Sex Outcome Treatment
    1 43 YR Other