FDA Adverse Event Malfunction Summary report: N

4083794

MDR report key: 4083794 · Received September 5, 2014

Report

Report Number: 4083794
Event Type: Malfunction
Date Received: September 5, 2014
Date of Event: September 29, 2014
Report Date: September 5, 2014
Product Problem: Yes
Report Source: User Facility report
Reporter Location: MD, US

Narratives

Description of Event or Problem · 1

ANESTHESIOLOGIST WAS INTUBATING PATIENT AND HOOKED HER UP TO THE VENTILATOR. THE PHYSICIAN THEN DIALED IN 8.0% DESFLURANE AND IT DELIVERED FOR A MINUTE THEN STOPPED DELIVERING. ANESTHESIOLOGY SUPERVISOR WAS CALLED TO THE ROOM AND EXPLAINED TO THE PROVIDER THAT THESE MACHINES VERY RARELY WILL START THEN READ AS A FAILURE. I RECOMMENDED WE REBOOT THE MACHINE WHICH 95% OF THE TIME CLEARS THE ISSUE. WHEN THE MACHINE WAS RE-BOOTED THE FAILURE MESSAGE WAS GONE. THE VAPORIZER THEN RAN NORMALLY AND DELIVERING THE AGENT ACCURATELY AND PROPERLY. THERE WAS NO HARM TO THE PATIENT ACCORDING TO THE PHYSICIAN. ANESTHESIOLOGY SUPERVISOR SPOKE WITH OUR BIOMED ANESTHESIA SERVICE REPRESENTATIVE AND HE WILL CONTACT THE SUPERVISOR WITH HIS INVESTIGATIVE FINDINGS. THE MACHINE WILL NOT BE USED UNTIL INSPECTION/SERVICE OF THIS MACHINE.

Patients

Seq	Age	Sex	Outcome	Treatment
1	29 YR