FDA Adverse Event Malfunction Summary report: N

TRIMA ACCEL

MDR report key: 3002929 · Received March 13, 2013

Report

Report Number
1722028-2013-01008
Event Type
Malfunction
Date Received
March 13, 2013
Date of Event
February 13, 2013
Report Date
February 14, 2013
Manufacturer
TERUMO BCT
Product Code
GKT
PMA / PMN Number
BK120017
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
AZ, US
Reporter Occupation
HEALTH PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

INVESTIGATION: THE DEVICE HISTORY RECORD (DHR) WAS REVIEWED FOR THIS LOT. THERE WERE NO ISSUES NOTED IN THE DHR THAT WOULD HAVE CONTRIBUTED TO THE ELEVATED WBC COUNT THAT THE CUSTOMER EXPERIENCED. THE RUN DATA FILE WAS ANALYZED FOR THIS EVENT. ROOT CAUSE: THE ANALYSIS OF THE RUN DATA FILE 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 LINE MAY 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 HEX IN THE HEX HOLDER MAY CONTRIBUTE TO THE ABOVE. AN INTERNAL CAPA HAS BEEN INITIATED TO EVALUATE REPORTS OF ELEVATED RWBCS RELATED TO PLASMA LINE OCCLUSIONS.

Description of Event or Problem · 1

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. DONOR UNIT #: (B)(6) 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
105714 TRIMA ACCEL TRIMA ACCEL ENHANCED PLT, PLS, RBC SET GKT TERUMO BCT 01V1106

Patients

Seq Age Sex Outcome Treatment
1 Other