BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HOMECHOICE AUTOMATED PD SET WITH CASSETTE

    MDR report key: 2230372 · Received September 1, 2011

    Report

    Report Number
    1423500-2011-11508
    Event Type
    Malfunction
    Date Received
    September 1, 2011
    Date of Event
    August 8, 2011
    Report Date
    August 8, 2011
    Manufacturer
    BAXTER HEALTHCARE - MOUNTAIN HOME
    Product Code
    FKX
    PMA / PMN Number
    K923065
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). PER THE CUSTOMER THE SAMPLE WAS DISCARDED AND THE LOT NUMBER WAS UNKNOWN, THEREFORE NO EVALUATION OR BATCH REVIEW COULD BE PERFORMED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE FILED.

    Additional Manufacturer Narrative · 1

    (B)(4). THIS REPORT FOR A SYSTEM ERROR 2240 (AIR IN SET) WAS NOT CONFIRMED. BASED ON THE INFORMATION GATHERED DURING BAXTER'S INVESTIGATION, THE ROOT CAUSE OF THE REPORT COULD NOT BE DETERMINED. SIMILAR REPORTS HAVE BEEN RECEIVED BY BAXTER FOR THE REPORTED PROBLEM. THE ROOT CAUSE INVESTIGATION IS IN PROGRESS THROUGH (B)(4).

    Description of Event or Problem · 1

    THE PATIENT CONTACTED BAXTER'S TECHNICAL SERVICE CENTER REGARDING A SYSTEM ERROR (SE) 2367, WHICH OCCURRED ON THE HOMECHOICE PRO DURING USE DURING DWELL 5 OF 5. THE ALARM WAS CLEARED BY THE CAREGIVER (CG). THE BAXTER TECHNICAL SERVICE REPRESENTATIVE (TSR) HAD THE CG REVIEW THE ALARM LOG AND A SE 2240 (AIR IN SET) OCCURRED PRIOR TO THE SE 2367. THE TSR EXPLAINED THE ALARM AND THE POSSIBLE REASONS FOR THE ALARM TO OCCUR. SINCE THE PATIENT WAS CONNECTED AT THE TIME OF THE ALARM THE TSR ADVISED THE CG TO CALL THE REGISTERED NURSE (RN) TO LET THE RN KNOW ABOUT THE AIR DETECT ALARM. THE TSR REVIEWED THE PROPER PROCEDURES PER THE USER MANUAL WITH THE CG. THERE WAS PATIENT INVOLVEMENT BUT THERE WAS NO PATIENT INJURY OR MEDICAL INTERVENTION INDICATED AT THE TIME OF THE INITIAL REPORT. BAXTER PRODUCT SURVEILLANCE CONTACTED THE REGISTERED NURSE (RN) ON (B)(6) 2011 REGARDING THE REPORTED SE 2240. THE RN STATED, THE CG DID NOT MAKE THEM AWARE OF THE ALARM AND THAT AS FAR AS THEY KNEW THE PATIENT WAS CONTINUING THERAPY ON THE CYCLER SUCCESSFULLY. THERE WAS NO PATIENT INJURY OR MEDICAL INTERVENTION REPORTED. NO FURTHER INFORMATION WAS AVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 HOMECHOICE AUTOMATED PD SET WITH CASSETTE SYSTEM, PERITONEAL, AUTOMATIC DELIVERY FKX BAXTER HEALTHCARE - MOUNTAIN HOME

    Patients

    Seq Age Sex Outcome Treatment
    1 12 YR HOMECHOICE PRO