BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCESS

    MDR report key: 2231863 · Received September 1, 2011

    Report

    Report Number
    6000001-2011-22163
    Event Type
    Malfunction
    Date Received
    September 1, 2011
    Date of Event
    July 26, 2011
    Report Date
    August 13, 2011
    Manufacturer
    BAXTER HEALTHCARE
    Product Code
    FPA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IL, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE SAMPLE IS NOT AVAILABLE FOR EVALUATION; THEREFORE, THE CONDITION CANNOT BE CONFIRMED OR DUPLICATED AND THE ASSIGNABLE ROOT CAUSE COULD NOT BE DETERMINED. THE DEVICE USED IN THIS SITUATION IS UNKNOWN; THEREFORE, IT DOES NOT CONTAIN A US 510K NUMBER. IF ADDITIONAL INFORMATION OR SAMPLES BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED.

    Description of Event or Problem · 1

    DURING A REVIEW OF THE PUMP'S EVENT HISTORY BY BAXTER PERSONNEL, A COLLEAGUE INFUSION PUMP EXPERIENCED AN UPSTREAM OCCLUSION ALARM AFTER ONE MINUTE OR MORE OF DELIVERY PRIOR TO A MANUAL TUBE RELEASE (MTR) ACTIVATION. THE MTR ACTIVATION INDICATED THAT AN UNKNOWN SET WAS REPLACED. THIS CONDITION HAD THE POTENTIAL TO INTERRUPT DELIVERY. THIS REPORT WILL ADDRESS THE POSSIBILITY THAT THE UNKNOWN SET WAS DEFECTIVE CAUSING THE UPSTREAM OCCLUSION ALARM. PATIENT INVOLVEMENT IS UNKNOWN. THERE WAS NO PATIENT INJURY OR MEDICAL INTERVENTION REPORTED FOR THIS REPORT. NO ADDITIONAL INFORMATION IS AVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCESS SET, ADMINISTRATION, INTRAVASCULAR FPA BAXTER HEALTHCARE

    Patients

    Seq Age Sex Outcome Treatment
    1