BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    8100 ALARIS PUMP MODULE

    MDR report key: 11137777 · Received January 8, 2021

    Report

    Report Number
    2016493-2021-02929
    Event Type
    Malfunction
    Date Received
    January 8, 2021
    Report Date
    January 24, 2020
    Manufacturer
    CAREFUSION SD
    Product Code
    FRN
    UDI-DI
    10885403810015
    PMA / PMN Number
    K133532
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 1

    THE CUSTOMER REPORTED PROBLEM WAS CONFIRMED. A REVIEW OF THE DEVICE HISTORY RECORD IN SAP FOR SN (B)(4). WAS PERFORMED FROM THE DATE OF THE MANUFACTURE TO DATE OF THE RELEASE OF PRODUCT, WHICH CONFIRMED THAT THIS DEVICE WAS NOT INVOLVED IN A PRODUCTION FAILURE, AND PRODUCT WAS NOT RETURNED FOR SERVICING WHICH NOT CORRELATES TO THE CUSTOMER REPORTED ISSUE. A REVIEW OF THE COMPLAINT HISTORY RECORD IN THE TRACKWISE WAS PERFORMED FOR THE SN (B)(4). WHICH CONFIRMED NO SIMILAR COMPLAINTS WITH THE SAME OR RELATED FAILURE MODE. THE CUSTOMER STATED THAT THERE WAS NO PATIENT INVOLVEMENT.

    Description of Event or Problem · 1

    BD QUALITY ADVOCATE, THIS NOTIFICATION IS TO INFORM YOU THAT A NEW CASE HAS BEEN CREATED WITH THE COMPLAINT TYPE CATEGORY INFUSION CA. CASE #: 00971527 CASE SUBJECT: NPI 8100 ERROR 210.5020 ACCOUNT NAME: WAKE FOREST BAPTIST HEALTH LEXINGTON MEDICAL CENTER ACCOUNT #: 1393401 ASSET NAME: 8100 PUMP MODULE V8.5.29.0 ASSET LOCATION: CONTACT: BILL HALMI CONTACT EMAIL: [email protected] CONTACT PHONE: 743-333-9548 CONTACT MOBILE: PATIENT OR USER INVOLVEMENT: NO PATIENT OR USER HARM: NO CASE DESCRIPTION: CALLER HAS AN 8100 MODULE GIVING A 210.5020 ERROR. SN: (B)(4). FAILURE DEVICE TYPE: FAILURE PROBLEM TYPE: FAILURE MODE: CASE RESOLUTION: BIOMED TRIED ANOTHER LOGIC BOARD AND DID NOT FIX THE ISSUE. USED KA 12137 ALAIRS INFUSION ERROR 210.5020 AND RECOMMENDED HE CHECK THE DOOR HARNESS AND THEN REPLACE THE DISPLAY BOARD. GAVE PART NUMBER TO DISPLAY BOARD AND BIOMED ENDED CALL. REF:_00D30Y0YR._5000L1QJOGT:REF

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    38610 8100 ALARIS PUMP MODULE PUMP, INFUSION FRN CAREFUSION SD 8100 10885403810015

    Patients

    Seq Age Sex Outcome Treatment
    1