BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ALARIS SYSTEM

    MDR report key: 14631123 · Received June 8, 2022

    Report

    Report Number
    2016493-2022-151382
    Event Type
    Malfunction
    Date Received
    June 8, 2022
    Date of Event
    May 17, 2022
    Report Date
    June 13, 2022
    Manufacturer
    CAREFUSION SD
    Product Code
    FRN
    UDI-DI
    10885403810015
    PMA / PMN Number
    K133532
    Removal / Correction Number
    Z-2718-2020, Z-1768-2019
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    A DEVICE HISTORY RECORD REVIEW IS PERFORMED ON EACH DEVICE REPORTED IN A MDR REPORTABLE EVENT ALONG WITH OTHER METHODS OF INVESTIGATION AS CODED IN SECTION H6 OF THIS MDR REPORT. PER 803.52(F)(11)(III) THE INFORMATION PROVIDED WAS OBTAINED FROM SERVICING ACTIVITIES PERFORMED ON THE DEVICE. THERE WERE NO ADDITIONAL DETAILS OBTAINABLE OR PROVIDED AT THE TIME OF SERVICE. SEE MANUFACTURER NARRATIVE.

    Additional Manufacturer Narrative · 0

    CORRECTION : ANNEX B : B21 ANNEX C : C21 ANNEX D : D16 ADDITIONAL INFORMATION : DEVICE AVAILABLE FOR EVAL, RETURNED TO MANUFACTURER ON, DEVICE RETURN TO MANUF ., DEVICE EVAL BY MANUFACTURE, REMEDIAL ACTION REQUIRED, REMEDIAL ACTION #. ANNEX A : A1301, A040502, A0404 ANNEX G : G04100, G02017, G0204002 ANNEX B : B01 ANNEX C : C070602, C0201, C0601 ANNEX D : D01, D02 H3 OTHER TEXT : SEE MANUFACTURER NARRATIVE.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT THE DEVICE HAD DISPLAYED ERROR CODE 210.6021. THERE WAS NO PATIENT INVOLVEMENT.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT THE DEVICE HAD DISPLAYED ERROR CODE 210.6021. THERE WAS NO PATIENT INVOLVEMENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    13604 ALARIS SYSTEM PUMP, INFUSION FRN CAREFUSION SD 8100 10885403810015

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown