BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    VENTED HUMIDIFICATION CHAMBER

    MDR report key: 3962258 · Received July 28, 2014

    Report

    Report Number
    9611451-2014-00661
    Event Type
    Malfunction
    Date Received
    July 28, 2014
    Date of Event
    July 1, 2014
    Report Date
    July 8, 2014
    Manufacturer
    FISHER & PAYKEL HEALTHCARE LTD
    Product Code
    BTT
    PMA / PMN Number
    K934140
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    JA
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). METHOD: THE COMPLAINT MR290 CHAMBER WAS RETURNED TO FISHER & PAYKEL HEALTHCARE (B)(4) AND WAS VISUALLY INSPECTED AND CONNECTED TO A WATER BAG TO CHECK FOR LEAK. RESULTS: DURING TESTING WITH A WATER BAG A DROP OF WATER BEGAN TO BUILD AT THE CONNECTION BETWEEN THE FEEDSET TUBE AND WATER BAG SPIKE. INSPECTION OF THE COMPLAINT FEEDSET TUBE AND WATER BAG SPIKE REVEALED THAT THERE WAS SUFFICIENT GLUE AT THE CONNECTION BUT THAT THE GLUE WAS ONLY PARTLY BONDED. A LOT CHECK REVEALED NO OTHER COMPLAINTS FOR LOT 130704. CONCLUSION: IT IS POSSIBLE THAT THE DETACHING OF THE SPIKE OCCURRED AS A RESULT OF PULLING ON THE TUBE INSTEAD OF THE SPIKE WHEN CHANGING THE WATER BAG. WE HAVE CONDUCTED EXTENSIVE TESTING OF THE MR290 CHAMBER, WITH PARTICULAR EMPHASIS ON FEEDSET BREAKS. SIGNIFICANTLY WE HAVE NOT BEEN ABLE TO REPLICATE FAILURE OF THE FEEDSET TUBE AT THE CHAMBER DOME OR WATER BAG SPIKE IN ANY OF OUR TESTING. THE SPECIFICATION FOR THE CHAMBER REQUIRES THAT THE FEEDSET TUBE SHOULD HAVE A BREAKING STRAIN OF 30 NEWTONS. DURING PRODUCTION, PULL TESTING OF THE FEEDSET STRENGTH AT BOTH SPIKE AND DOME END IS PERFORMED EVERY HOUR ON MR290 CHAMBERS FROM EACH PRODUCTION LINE. ADDITIONALLY ALL CHAMBERS ARE PRESSURE TESTED BEFORE THEY LEAVE THE PRODUCTION LINE AND ANY HOLES OR LEAKS IN THE FEEDSET ARE IDENTIFIED DURING THIS PROCESS. CHAMBERS THAT FAIL ANY OF THESE TESTS ARE DISCARDED. THE USER INSTRUCTIONS WHICH ACCOMPANY THE MR290 CHAMBER STATE THE FOLLOWING: - SET APPROPRIATE VENTILATOR ALARMS. - PERFORM A PRESSURE AND LEAK TEST ON THE BREATHING SYSTEM AND CHECK FOR OCCLUSIONS BEFORE CONNECTING TO A PATIENT. (B)(4).

    Description of Event or Problem · 1

    A HOSPITAL IN (B)(6) REPORTED VIA OUR DISTRIBUTOR THAT WATER LEAK OCCURRED FROM THE CONNECTION BETWEEN THE BAG SPIKE AND WATER FEEDSET TUBE OF AN MR290 HUMIDIFICATION CHAMBER WHEN THEY CONNECTED THE SPIKE TO THE WATER BOTTLE BEFORE USE ON A PATIENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    439603 VENTED HUMIDIFICATION CHAMBER AUTOFEED CHAMBER BTT FISHER & PAYKEL HEALTHCARE LTD MR290V 1307040105

    Patients

    Seq Age Sex Outcome Treatment
    1 FISHER & PAYKEL RT204 BREATHING CIRCUIT