TRIMA ACCEL
Report
- Report Number
- 1722028-2013-01195
- Event Type
- Malfunction
- Date Received
- May 14, 2013
- Date of Event
- April 15, 2013
- Report Date
- April 17, 2013
- Manufacturer
- TERUMO BCT
- Product Code
- GKT
- PMA / PMN Number
- BK120017
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- NY, US
- Reporter Occupation
- HEALTH PROFESSIONAL
Narratives
INVESTIGATION: THE RUN DATA FILE (RDF) WAS ANALYZED FOR THIS EVENT. THE SIGNALS IN THE RUN DATA FILE INDICATE THAT THE HIGHER THAN EXPECTED WBC CONTENT IN THE PLATELET PRODUCT WAS LIKELY A RESULT OF AN ESCAPE OF WBCS FROM THE LRS CHAMBER TOWARD THE END OF THE PROCEDURE. THERE ARE NO EVENTS (ADJUSTMENTS, CHANGES IN PUMP SPEED, SUBSTATE CHANGES,ETC.) IN THE PROCEDURE THAT CORRESPONDS WITH THE ONSET OF THE OVERLOADING OF THE LRS CHAMBER. BASED ON THE AVAILABLE INFORMATION, IT CANNOT BE RULED OUT THAT THIS LEUKOREDUCTION FAILURE COULD BE DONOR-RELATED. INVESTIGATION EVALUATION AND CORRECTIVE ACTIONS ARE IN-PROCESS. A FOLLOW-UP REPORT WILL BE PROVIDED
ROOT CAUSE: THIS DISPOSABLE SET WAS UNAVAILABLE FOR SPECIFIC ROOT CAUSE ANALYSIS. A DEFINITIVE ROOT CAUSE FOR THE OBSERVED LEUKO REDUCTION FAILURE REMAINS UNDETERMINED AT THIS TIME. POSSIBLE ROOT CAUSES WERE PROVIDED IN THE INITIAL REPORT FOR THIS EVENT.
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 |
|---|---|---|---|---|---|---|---|
| 213355 | TRIMA ACCEL | TRIMA ACCEL PLATELET, PLASMA SET | GKT | TERUMO BCT | 02V2901 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Other |