BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COMBISET WITH BVM

    MDR report key: 1930185 · Received November 18, 2010

    Report

    Report Number
    8030665-2010-00063
    Event Type
    Malfunction
    Date Received
    November 18, 2010
    Date of Event
    October 27, 2010
    Report Date
    November 18, 2010
    Manufacturer
    REYNOSA MANUFACTURING
    Product Code
    FJK
    PMA / PMN Number
    K962081
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    NO INFORMATION

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE MFR IS REVIEWING THE DESIGN HISTORY FILE AND THE LOT AND MFG RECORDS FOR THIS PRODUCT. IN ADDITION, THE MFR HAS MADE VISITS TO THIS FACILITY TO OBSERVE THE CLINICAL PRACTICE AND COLLECT ADDITIONAL INFO THAT WILL BE HELPFUL TO THE INVESTIGATION. THE INVESTIGATION IS ONGOING AND A ROOT CAUSE HAS NOT YET BEEN DETERMINED AT THIS TIME.

    Description of Event or Problem · 1

    A REPORT HAS BEEN REC'D FROM (B)(6) OF A POSSIBLE BLOODLINE TUBING KINK ON THE ARTERIAL LINE OF THE BVM COMBISET BLOODLINE. REPORTEDLY, THE INCIDENT OCCURRED WHILE A PT WAS RECEIVING HEMODIALYSIS TREATMENT WHEN THE NURSE NOTICED THAT THE ARTERIAL LINE WAS KINKED AT THE CUVETTE AT THE BVM OUTPUT. ALTHOUGH THERE WAS PT INVOLVEMENT, THERE WAS NO INJURY TO THE PT AND NO MEDICAL INTERVENTION REQUIRED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 COMBISET WITH BVM DIALYSIS BLOODLINE TUBING FJK REYNOSA MANUFACTURING NA 10LR01269

    Patients

    Seq Age Sex Outcome Treatment
    1 NA