BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ALARIS PUMP MODULE

    MDR report key: 10744967 · Received October 27, 2020

    Report

    Report Number
    2016493-2020-28445
    Event Type
    Malfunction
    Date Received
    October 27, 2020
    Report Date
    September 18, 2020
    Manufacturer
    CAREFUSION SD
    Product Code
    FRN
    UDI-DI
    10885403810015
    PMA / PMN Number
    K133532
    Removal / Correction Number
    Z-1768-2019; Z-2822-2020
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GA, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 0

    THE CUSTOMER REPORTED PROBLEM WAS UNKNOWN/NOT PROVIDED. THE DEVICE WAS REPAIRED, PASSED ALL REQUIRED TESTING AND SPECIFICATIONS, AND RELEASED BACK TO THE CUSTOMER. THERE ARE CAPA #'S NOTED FOR THE FOLLOWING PARTS REPLACED THAT HAVE AN ALREADY EXISTING CAPA. 1143616 FOR DIM U4 DISPLAY SEGMENTS. CA-2018-0161- IUI DAMAGES. A REVIEW OF THE DEVICE HISTORY RECORD FOR SN (B)(6) WAS PERFORMED FROM DATE OF MANUFACTURE 11/28/2012 TO THE PRESENT DATE 10/15/2020 AND NOTE THAT THIS DEVICE HAS BEEN RETURNED FOR SERVICE I TIME WHICH CORRELATES TO THE CUSTOMER REPORTED ISSUE OR SERVICE REPAIRS. ALSO, THERE WERE NO PRODUCTION FAILURES INDICATED ON THE SOURCE DEVICE.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT THE 8100 PUMP MODULE HAS AN UNKNOWN/ NOT PROVIDED ISSUE. THERE WAS NO PATIENT INVOLVEMENT.

    Additional Manufacturer Narrative · 1

    THE CUSTOMER REPORTED PROBLEM WAS UNKNOWN/NOT PROVIDED. THE DEVICE WAS REPAIRED, PASSED ALL REQUIRED TESTING AND SPECIFICATIONS, AND RELEASED BACK TO THE CUSTOMER. THERE ARE CAPA #'S NOTED FOR THE FOLLOWING PARTS REPLACED THAT HAVE AN ALREADY EXISTING CAPA. 1143616 FOR DIM DISPLAY SEGMENTS. (B)(4) DAMAGES. A REVIEW OF THE DEVICE HISTORY RECORD FOR SN (B)(4) WAS PERFORMED FROM DATE OF MANUFACTURE 11/28/2012 TO THE PRESENT DATE 10/15/2020 AND NOTE THAT THIS DEVICE HAS BEEN RETURNED FOR SERVICE I TIME WHICH CORRELATES TO THE CUSTOMER REPORTED ISSUE OR SERVICE REPAIRS. ALSO, THERE WERE NO PRODUCTION FAILURES INDICATED ON THE SOURCE DEVICE.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE 8100 PUMP MODULE HAS AN UNKNOWN/ NOT PROVIDED ISSUE. THERE WAS NO PATIENT INVOLVEMENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1208889 ALARIS PUMP MODULE PUMP, INFUSION FRN CAREFUSION SD 8100 10885403810015

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown