TRIMA ACCEL
Report
- Report Number
- 1722028-2013-00936
- Event Type
- Malfunction
- Date Received
- February 14, 2013
- Date of Event
- January 15, 2013
- Report Date
- January 16, 2013
- Manufacturer
- TERUMO BCT
- Product Code
- GKT
- PMA / PMN Number
- BK120017
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- AU
- Reporter Occupation
- HEALTH PROFESSIONAL
Narratives
INVESTIGATION: THE RUN DATA FILE (RDF) WAS ANALYZED FOR THIS EVENT. ANALYSIS OF THE RDF DID NOT FIND A CONCLUSIVE CAUSE FOR THE HIGHER THAN EXPECTED WBC CONTENT REPORTED FOR THIS COLLECTION. THE SIGNALS IN THE RUN DATA FILE INDICATE IT IS POSSIBLE, THOUGH NOT CONCLUSIVE, THAT THE PLASMA LIMAY HAVE BEEN PARTIALLY OCCLUDED NEAR THE END OF THE PROCEDURE. IF THE PLASMA LINE DOES NOT CONTRIBUTE PROPERLY TO THE PLATELET PUMP, IT COULD CAUSE THE FLOW THROUGH THE LRS CHAMBER TO BE HIGHER THAN THE SYSTEM EXPECTS, POSSIBLY ALLOWING SOME WBCS TO ESCAPE. ORIENTATION OF THE HEXIN THE HEX HOLDER MAY CONTRIBUTE TO THE ABOVE. INVESTIGATION EVALUATION AND CORRECTIVE ACTIONS ARE IN-PROCESS. A FOLLOW-UP REPORT WILL BE PROVIDED.
ROOT CAUSE: THE DISPOSABLE SET WAS NOT AVAILABLE FOR RETURN AND EVALUATION. ANALYSIS OF THE RDF DID NOT FIND A CONCLUSIVE CAUSE FOR THE HIGHER THAN EXPECTED WBC CONTENT REPORTED FOR THIS COLLECTION. POSSIBLE ROOT CAUSES WERE PROVIDED IN THE INITIAL REPORT FOR THIS EVENT. AN INTERNAL CAPA HAS BEEN INITIATED TO EVALUATE REPORTS OF ELEVATED WBCS RELATED TO PLASMA LINE OCCLUSIONS.
THE CUSTOMER WOULD LIKE THE RUN DATA FILE INVESTIGATED TO DETERMINE A POSSIBLE CAUSE FOR THE ELEVATED WHITE BLOOD CELL (WBC) CONTENT IN THE PLATELET PRODUCT. THERE WAS NOT A TRANSFUSION RECIPIENT OR PATIENT INVOLVED AT THE TIME OF THE RESIDUAL WBC TESTING, THEREFORE, NO PATIENT INFORMATION IS REASONABLY KNOWN AT THE TIME OF THE EVENT. THE DISPOSABLE SET IS UNAVAILABLE FOR RETURN BECAUSE THE CUSTOMER DISCARDED IT. THIS REPORT IS BEING FILED DUE TO A DEVICE MALFUNCTION THAT HAS THE POTENTIAL FOR INJURY.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 66126 | TRIMA ACCEL | TRIMA ACCEL ENHANCED PLT, PLS, RBC SET | GKT | TERUMO BCT |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Other |