BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PLUM LC OL CNVRTBL P

    MDR report key: 1950350 · Received December 14, 2010

    Report

    Report Number
    9615050-2010-00254
    Event Type
    Malfunction
    Date Received
    December 14, 2010
    Date of Event
    November 23, 2010
    Report Date
    November 23, 2010
    Manufacturer
    HOSPIRA COSTA RICA LTD.
    Product Code
    FRN
    PMA / PMN Number
    K865060
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THE CUSTOMER INDICATED THAT THE DEVICE WAS DISCARDED. THE LOT NUMBER OF THE DEVICE THAT WAS IN USE IS UNK. THE CUSTOMER CONTACT IDENTIFIED FOUR POSSIBLE LOT NUMBERS. THE POSSIBLE LOT NUMBERS ARE 920125H, 910235H, 910245H, 881995H. A REP DEVICE FROM AN UNK LOT NUMBER IS EXPECTED TO BE RETURNED FOR INVESTIGATION. IT HAS NOT YET BEEN RECEIVED. THIS REPORT REPRESENTS ALL THE INFO KNOWN BY THE REPORTER UPON QUERY BY HOSPIRA PERSONNEL. (B)(4).

    Description of Event or Problem · 1

    THE CUSTOMER CONTACT REPORTED A LEAK OF A CHEMOTHERAPEUTIC AGENT. THE PRIMARY PLUMSET WAS BEING USED TO DELIVER AN UNSPECIFIED VOLUME OF NORMAL SALINE. AT AN UNSPECIFIED TIME, THE OPTION-LOK MALE ADAPTER OF A SECOND PLUMSET WAS CONNECTED TO THE CLAVE Y-SITE OF THE PRIMARY PLUMSET FOR DELIVERY OF AN UNSPECIFIED CHEMOTHERAPEUTIC AGENT. THE CUSTOMER CONTACT REPORTED DIFFICULTY IN CONNECTING THE OPTION-LOK MALE ADAPTER TO THE CLAVE Y-SITE. AFTER AN UNSPECIFIED LENGTH OF TIME IN USE, THE NURSE NOTED LEAKAGE OF THE CHEMOTHERAPEUTIC AGENT AT THE CONNECTION OF THE OPTION-LOK MALE ADAPTER AND THE CLAVE Y-SITE. IT WAS REPORTED THAT AN UNSPECIFIED VOLUME OF THE CHEMOTHERAPEUTIC AGENT LEAKED ONTO THE PT'S CLOTHES. THE CLOTHES WERE DISCARDED AND THE SPILL WAS CLEANED UP ACCORDING TO THE USER FACILITY'S PROTOCOL. THE TUBING SETS WERE REPLACED AND THE THERAPY WAS RESUMED. THERE WERE NO REPORTED ADVERSE PT EFFECTS AND NO DELAY IN THERAPY CRITICAL FOR THIS PT. NO MEDICAL INTERVENTIONS WERE REQUIRED. THOUGH REQUESTED, NO ADDITIONAL INFO WAS PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PLUM LC OL CNVRTBL P 80FRN FRN HOSPIRA COSTA RICA LTD. NA UNK5H

    Patients

    Seq Age Sex Outcome Treatment
    1 LIFESHIELD IV PLUMSET, LIST# 12030, LOT# UNK