BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCUSOL

    MDR report key: 2133757 · Received June 20, 2011

    Report

    Report Number
    1423500-2011-07823
    Event Type
    Malfunction
    Date Received
    June 20, 2011
    Date of Event
    April 1, 2010
    Report Date
    April 28, 2010
    Manufacturer
    BAXTER HEALTHCARE - CASTLEBAR
    Product Code
    KPO
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    UK
    Reporter Occupation
    PHARMACIST

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE SAMPLE WAS REQUESTED BUT WAS NEVER RECEIVED BY BAXTER FOR EVALUATION. A BATCH REVIEW WAS CONDUCTED AND NO ISSUES WERE FOUND RELATED TO THE REPORTED CONDITION DURING THE MANUFACTURE OF THE LOT. SAMPLES FOR SIMILAR COMPLAINTS HAVE BEEN ANALYSED. THE PRECIPITATES WERE ISOLATED AND INSPECTED USING VARIOUS LABORATORY ANALYTICAL METHODS. THE ANALYSES CONCLUDED THAT THE PRECIPITATES OBSERVED ARE CALCIUM CARBONATES. A (B)(4) HAS BEEN SET UP TO FURTHER INVESTIGATE THIS ISSUE. INVESTIGATIONS INTO THIS ISSUE BY THE TEAM HAVE PROGRESSED. THE PH OF THE SOLUTION HAS BEEN IDENTIFIED AS THE PRIMARY ROOT CAUSE OF THIS PROBLEM. ANY ACCUSOL PRODUCT MANUFACTURED AFTER AUGUST 2008 WITH A PH ABOVE 7.3 AT FINAL ANALYSIS IS NOT RELEASED. A MORE LONG-TERM PREVENTATIVE PLAN IS CURRENTLY BEING EVALUATED BY THE TEAM TO PERMANENTLY ELIMINATE THIS PROBLEM. THIS INTERNATIONAL PRODUCT IS DISTRIBUTED OUTSIDE THE U.S. AND DOES NOT HAVE A 510K NUMBER, BUT IT IS BEING REPORTED AS IT IS THE SAME OR SIMILAR TO A PRODUCT DISTRIBUTED WITHIN THE U.S.

    Description of Event or Problem · 1

    THIS IS A CASE, WHICH WAS REPORTED TO BAXTER (B)(4) ON (B)(4) 2010. THE COMPLAINT WAS RECEIVED FROM (B)(4) HOSPITAL AND REFERS TO AN INCIDENT INVOLVING AN ACCUSOL 35 5000ML. THE REPORTER STATED THAT A FEMALE PATIENT WAS LINKED TO 3 BAGS OF ACCUSOL . THERE APPEARED TO BE VERY SMALL AIR BUBBLES 48 HOURS AFTER THERAPY BEGAN, BUT UPON CLOSER INSPECTION A VERY SMALL AMOUNT OF CRYSTALLIZATION WAS NOTED. THE CRYSTALLIZATION WAS NOTICED AFTER THE FLUID HAD BEEN HEATED AND THEN COOLED DOWN. NO ADDITIONAL INFORMATION WAS AVAILABLE. NO PATIENT INJURY OR MEDICAL INTERVENTION WAS REPORTED BY THE CUSTOMER.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCUSOL DIALYSATE CONCENTRATE FOR HEMODIALYSIS (LIQUID OR POWDER) KPO BAXTER HEALTHCARE - CASTLEBAR 09J05G72

    Patients

    Seq Age Sex Outcome Treatment
    1