BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HOMECHOICE AUTOMATED PD SET WITH CASSETTE

    MDR report key: 2994130 · Received March 8, 2013

    Report

    Report Number
    1416980-2013-05572
    Event Type
    Malfunction
    Date Received
    March 8, 2013
    Date of Event
    January 1, 2013
    Report Date
    February 26, 2013
    Manufacturer
    BAXTER HEALTHCARE - MOUNTAIN HOME
    Product Code
    FKX
    PMA / PMN Number
    K923065
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THIS COMPLAINT WAS NOT CONFIRMED AND THE ROOT CAUSE COULD NOT BE DETERMINED BECAUSE THE DISPOSABLE SET WAS NOT RETURNED TO BAXTER FOR EVALUATION, A LOT NUMBER WAS NOT PROVIDED FOR A BATCH REVIEW, AND THE USER DID NOT DESCRIBE ANY TYPE OF USE ERRORS OR OTHER ISSUES THAT MIGHT HAVE CAUSED THE REPORTED EVENT.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PATIENT HAD A LEAK DURING PERITONEAL DIALYSIS (PD) THERAPY. THE LEAK WAS OBSERVED BETWEEN THE CONNECTION OF THE CASSETTE AND THE SOLUTION BAG. THERE WAS PATIENT INVOLVEMENT, BUT THERE WAS NO PATIENT INJURY OR MEDICAL INTERVENTION INDICATED AT THE TIME OF THE INITIAL REPORT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    99325 HOMECHOICE AUTOMATED PD SET WITH CASSETTE SYSTEM, PERITONEAL, AUTOMATIC DELIVERY FKX BAXTER HEALTHCARE - MOUNTAIN HOME

    Patients

    Seq Age Sex Outcome Treatment
    1 SOLUTION BAG