FDA Adverse Event Malfunction Summary report: N

HOMECHOICE

MDR report key: 3052280 · Received April 11, 2013

Report

Report Number: 1416980-2013-09016
Event Type: Malfunction
Date Received: April 11, 2013
Date of Event: February 27, 2013
Report Date: March 21, 2013
Manufacturer: BAXTER HEALTHCARE - LARGO
Product Code: FKX
PMA / PMN Number: K102936
Removal / Correction Number: 1423500-01/08/10-001-C
Product Problem: Yes
Report Source: Manufacturer report
Reporter Location: MX
Reporter Occupation: PATIENT

Narratives

Additional Manufacturer Narrative · 1

(B)(4).THE DEVICE WAS RETURNED TO BAXTER, AND THE EVALUATION IS COMPLETE. THIS COMPLAINT IS AN ANCILLARY SERVICE EVENT. THE REPORTED DIFFICULTY OF AN IIPV EVENT WAS CONFIRMED THROUGH AN EVENT HISTORY LOG REVIEW. THE CAUSE WAS FALSE EMPTY DETECT AND USE ERROR, INAPPROPRIATE BYPASS OF THE LOW DRAIN VOLUME ALARM, NOT INCLUDING I-DRAIN. HOMECHOICE APD SYSTEMS PATIENT AT-HOME GUIDE DESCRIBES THE PROCEDURE FOR BYPASSING A LOW DRAIN VOLUME ALARM. THE TEXT ON PAGES 18-45 AND 18-46 INCLUDES, "BYPASSING A LOW DRAIN VOLUME ALARM CAN LEAVE FLUID IN THE PERITONEAL CAVITY AND RESULT IN AN INCREASED INTRAPERITONEAL VOLUME (IIPV) SITUATION." IF ANY ADDITIONAL INFORMATION IS RECEIVED, A FOLLOW-UP WILL BE SENT.

Description of Event or Problem · 1

DURING EVALUATION OF A RETURNED HOMECHOICE MACHINE, ONE INCREASED INTRA-PERITONEAL VOLUME (IIPV) EVENT WAS IDENTIFIED WHICH OCCURRED IN THE THERAPY INITIATED ON (B)(6) 2013 AT 23:25:50. DURING NIGHT DRAIN CYCLE FIVE, THE PATIENT'S ULTRAFILTRATION READING WAS 1916ML, INDICATING THE HOME PATIENT (HP) DRAINED 1916ML MORE THAN THEIR MAXIMUM PROGRAMMED FILL VOLUME OF 2000ML. THIS INFORMATION MEETS IIPV CRITERIA. NO ADDITIONAL INFORMATION IS AVAILABLE.

Devices

Seq	Brand	Generic	Product Code	Manufacturer	Model	Lot	UDI-DI
156817	HOMECHOICE	SYSTEM, PERITONEAL, AUTOMATIC DELIVERY	FKX	BAXTER HEALTHCARE - LARGO

Patients

Seq	Age	Sex	Outcome	Treatment
1