BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LIBERTY CYCLER SET, SINGLE CONN/EXT DL

    MDR report key: 3130324 · Received May 22, 2013

    Report

    Report Number
    8030665-2013-00313
    Event Type
    Malfunction
    Date Received
    May 22, 2013
    Date of Event
    April 23, 2013
    Report Date
    April 24, 2013
    Manufacturer
    REYNOSA MANUFACTURING
    Product Code
    FKX
    PMA / PMN Number
    K043363
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    THE DEVICE WAS NOT RETURNED TO THE MFR FOR PHYSICAL EVAL AND THE FAILURE MODE CANNOT BE CONFIRMED. HOWEVER, AN INVESTIGATION OF THE DEVICE MANUFACTURING RECORDS WAS CONDUCTED BY THE MFR. THERE WERE NO DEVIATIONS OR NONCONFORMANCES DURING THE MANUFACTURING PROCESS. IN ADDITION, THE BATCH RECORD REVIEW CONFIRMED THE LABELING, MATERIAL, AND PROCESS CONTROLS WERE WITHIN SPECIFICATION. THIS MEDWATCH REPORT IS ASSOCIATED WITH MFR #'S: 8030665-2013-00311, 803665-2013-00312, 8030665-2013-00314.

    Description of Event or Problem · 1

    A PERITONEAL DIALYSIS PT HAS REPORTED THAT DIALYSIS SOLUTION WAS LEAKING OUT OF THE CASSETTE AND INTO THE CYCLER. PT STATED THAT HER CARE TAKER NOTICED FLUID LEAKING FROM THE CYLINDER SET WHEN REMOVING THE PRODUCT FOLLOWING TREATMENT. THE CARE TAKER STATED HE NOTICED MOISTURE INSIDE THE CASSETTE DOOR UPON TERMINATION OF TREATMENT ON (B)(6) 2013. HE STATED THAT HE COULD NOT IDENTIFY THE LOCATION OF THE LEAK IN ANY INSTANCE. HE STATED THAT THE PT HAS NOTICED NO ILL EFFECTS. SAMPLE HAS NOT BEEN RETURNED TO THE MFR.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    227006 LIBERTY CYCLER SET, SINGLE CONN/EXT DL FKX REYNOSA MANUFACTURING 13BR08831

    Patients

    Seq Age Sex Outcome Treatment
    1 LIBERTY DIALYSIS CYCLER