FDA Adverse Event Malfunction Summary report: N

ADULT DUAL-HEATED EVAQUA BREATHING CIRCUIT

MDR report key: 2221143 · Received August 23, 2011

Report

Report Number
9611451-2011-00516
Event Type
Malfunction
Date Received
August 23, 2011
Date of Event
July 27, 2011
Report Date
July 29, 2011
Manufacturer
FISHER & PAYKEL HEALTHCARE LIMITED
Product Code
BZE
PMA / PMN Number
REFER TO H10
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
JA
Reporter Occupation
OTHER

Narratives

Additional Manufacturer Narrative · 1

(B)(4). THE RT340 ADULT DUAL-HEATED EVAQUA BREATHING CIRCUIT IS NOT SOLD IN THE USA BUT IT IS SIMILAR TO A PRODUCT SOLD IN THE USA. THE 510(K) FOR THAT PRODUCT IS K983112. METHOD: THE ELECTRICAL RESISTANCE OF THE HEATER WIRES IN THE INSPIRATORY AND EXPIRATORY TUBES OF THE RETURNED RT340 ADULT DUAL- HEATED EVAQUA BREATHING CIRCUIT WAS TESTED USING A MULTIMETER. A CONTINUITY TEST WAS USED TO LOCATE THE BREAK IN THE HEATER WIRES. RESULTS: AN ELECTRICAL RESISTANCE TESTING SHOWED THAT THE INSPIRATORY HEATER WIRE WAS OPEN CIRCUIT. CONTINUITY TESTING SHOWED THAT THE OPEN CIRCUIT IN THE INSPIRATORY HEATER WIRE WAS LOCATED IN THE CONNECTION BETWEEN THE HEATER WIRE AND THE HEATER WIRE PIN INSIDE THE OVERMOULDED PLUG. NO FAULT WAS FOUND WITH THE HEATER WIRE IN THE EXPIRATORY TUBE. A LOT CHECK REVEALED NO OTHER COMPLAINTS OF THIS NATURE FOR LOT NUMBER 110413. CONCLUSION: ELECTRICAL OPEN CIRCUITS IN HEATER WIRES ARE OFTEN ASSOCIATED WITH IMPROPER CRIMPING OF THE HEATER WIRE DURING PRODUCTION. ALL BREATHING CIRCUITS ARE ELECTRICALLY TESTED DURING PRODUCTION AND THOSE THAT FAIL ARE REJECTED. THIS SUGGESTS THE HEATER WIRE BECAME OPEN CIRCUIT POST PRODUCTION. (B)(4).

Description of Event or Problem · 1

A HOSPITAL IN (B)(6) REPORTED TO A FISHER & PAYKEL HEALTHCARE (FPH) FIELD REPRESENTATIVE THAT WHEN AN RT340 ADULT DUAL-HEATED EVAQUA BREATHING CIRCUIT WAS CONNECTED TO AN MR850 RESPIRATORY HUMIDIFIER, THE HUMIDIFIER "DID NOT INDICATE THE TEMPERATURE". THIS WAS NOTICED BEFORE USE ON A PATIENT. NO PATIENT CONSEQUENCE WAS REPORTED.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 ADULT DUAL-HEATED EVAQUA BREATHING CIRCUIT BZE BZE FISHER & PAYKEL HEALTHCARE LIMITED RT340 110413

Patients

Seq Age Sex Outcome Treatment
1