BEUDAMED
    FDA Adverse Event Injury Summary report: N

    NXSTAGE SYSTEM ONE

    MDR report key: 1222117 · Received November 5, 2008

    Report

    Report Number
    3003464075-2008-00552
    Event Type
    Injury
    Date Received
    November 5, 2008
    Date of Event
    October 13, 2008
    Report Date
    October 14, 2008
    Manufacturer
    NXSTAGE MEDICAL, INC.
    Product Code
    KDI
    PMA / PMN Number
    K050525
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    THE REPORTED BLOOD LOSS IS ATTRIBUTED TO THE OPERATOR NOT PERFORMING RINSEBACK OF THE PT'S BLOOD AS INSTRUCTED IN THE USER'S GUIDE. THE EXACT CAUSE OF THE ALARM IS NOT KNOWN. THE USER'S GUIDE INCLUDES PROBABLE CAUSES AND TROUBLESHOOTING STEPS FOR ALARMS. OCCASIONAL ALARMS DURING DIALYSIS ARE EXPECTED AND SHOULD NOT RESULT IN A BLOOD LOSS IF DEVICE LABELING IS FOLLOWED. A DIRECT CORRELATION BETWEEN NXSTAGE SYSTEM ONE AND THE REPORTED BLOOD LOSS CANNOT BE ESTABLISHED. NO SIMILAR PROBLEMS REPORTED SUBSEQUENT TO THIS EVENT. FACILITY STAFF HAS REVIEWED RINSEBACK PROCEDURES WITH THE OPERATOR. NXSTAGE MEDICAL CONSIDERS THIS REPORT CLOSED. NO ADDITIONAL INFO 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. A SYSTEM ALARM OCCURRED TOWARD THE END OF A ROUTINE HEMODIALYSIS TREATMENT. RINSEBACK WAS NOT PERFORMED, DUE TO THE OPERATOR NOT FOLLOWING THE PROPER RINSEBACK INSTRUCTIONS, 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 8087702

    Patients

    Seq Age Sex Outcome Treatment
    1 69 YR Other