INTELLIVUE MULTI MEASUREMENT SERVER X2
Report
- Report Number
- 9610816-2013-00059
- Event Type
- Malfunction
- Date Received
- March 12, 2013
- Report Date
- February 21, 2013
- Manufacturer
- PHILIPS MEDICAL SYSTEMS
- Product Code
- MHX
- PMA / PMN Number
- K071426
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- FR
- Reporter Occupation
- OTHER
Narratives
(B)(4). THE CUSTOMER SAID HE DOESN'T HAVE RECORDS OF SPEAKER BEING CHANGED. SPEAKER MALFUNCTION INOP CONFIRMED THE PROBLEM. WHEN THERE IS A LOSS OF AUDIO, THE DEVICE IS DESIGNED (AS DOCUMENTED IN THE RISK MANAGEMENT SUMMARY (RMS)) TO GENERATE A "SPEAKER MALFUNCT." INOP. IT IS CONSIDERED THAT THE INOP WOULD MAKE THE ISSUE IMMEDIATELY OBVIOUS TO USERS DURING CLOSE OBSERVATION OF THE PT. THE IMPORTANCE OF USING THE MONITORING EQUIPMENT IN CONJUNCTION WITH CLOSE PERSONAL OBSERVATION OF THE PT IS STATED IN THE PRODUCT LABELING. THE LABELING (WHICH WAS SEND WITH THE DEVICE) DESCRIBES PERSONAL SURVEILLANCE: "WARNING - DO NOT RELY EXCLUSIVELY ON THE AUDIBLE ALARM SYSTEM FOR PT MONITORING. ADJUSTMENT OF ALARM VOLUME TO A LOW LEVEL OR OFF DURING PT MONITORING MAY RESULT IN PT DANGER. REMEMBER THAT THE MOST RELIABLE METHOD OF PT MONITORING COMBINES CLOSE PERSONAL SURVEILLANCE WITH CORRECT OPERATION OF MONITORING EQUIPMENT." THIS WOULD ALLOW THE USER TO IMPLEMENT ALTERNATIVE METHODS OF MONITORING (IF NOT ALREADY APPLIED) PER HOSPITAL PROTOCOL, AND/OR TO TROUBLESHOOT THE MONITOR. THE VISUAL INOP, TOGETHER WITH THE ABOVE PRODUCT LABELING, IS CONSIDERED AS A SUFFICIENT MITIGATION OF RISK FROM A LOSS OF AUDIO. DESPITE THIS, PHILIPS HEALTHCARE HAS A POLICY TO REPORT A LOSS OF AUDIO, THEREFORE, THIS COMPLAINT HAS BEEN EVALUATED TO BE REPORTABLE. PHILIPS IS IN THE PROCESS OF OBTAINING ADD'L INFO REGARDING THIS INCIDENT AND THE COMPLAINT IS STILL UNDER INVESTIGATION. A FINAL REPORT WILL BE SUBMITTED ONCE THE INVESTIGATION IS COMPLETED.
THE CUSTOMER REPORTED THAT THE DEVICE ISSUED A "SPEAKER MALFUNCT." INOP TOGETHER WITH A LOSS OF AUDIO. THERE WAS NO ALLEGATION OF A DEATH OR A SERIOUS INJURY.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 104264 | INTELLIVUE MULTI MEASUREMENT SERVER X2 | MHX | PHILIPS MEDICAL SYSTEMS | M3002A |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |