FDA Adverse Event Injury Summary report: N

PULMONETIC SYSTEMS, INC.

MDR report key: 540241 · Received August 18, 2004

Report

Report Number
2031702-2004-00171
Event Type
Injury
Date Received
August 18, 2004
Date of Event
July 25, 2004
Report Date
August 18, 2004
Manufacturer
PULMONETIC SYSTEMS, INC.
Product Code
CAI
Removal / Correction Number
NA
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
CT, US
Reporter Occupation
PATIENT FAMILY MEMBER OR FRIEND

Narratives

Description of Event or Problem · 1

PT USING A DISPOSABLE PEDIATRIC CIRCUIT WITH PEEP AND WATER TRAP. FAMILY MEMBER HEARD A "HISSING" FROM VENT, BUT IT SEEMED OK. FAMILY MEMBER LATER NOTICED PT APPEARED TO BE HAVING TROUBLE BREATHING. FAMILY MEMBER LOOKED AT THE PEEP ON THE SCREEN-AND IT WAS "0". PT'S SPO2 DROPPED. NO ALARMS FOR LOW PEEP. FAMILY MEMBER IMMEDIATELY SWITCHED PT TO THEIR BACK UP VENT, WHICH WAS OK. PT RECOVERED QUICKLY. FAMILY MEMBER STATED DIAPHRAGM LOOKED "SHRIVELD." THEY CHANGED CIRCUIT ONE TIME PER WEEK. PT HAS LARGE LEAK, NO LOW MINUTE VOLUME ALARM SET - WAS A CONTINUOUS NUISANCE. FAMILY MEMBER ALLEGING PT HARM.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 PULMONETIC SYSTEMS, INC. BREATHING CIRCUIT WITH PEEP AND WATER TRAP, DISPOSIBLE CAI PULMONETIC SYSTEMS, INC. 11505 025569

Patients

Seq Age Sex Outcome Treatment
1 3 YR Required Intervention