FDA Adverse Event Malfunction Summary report: N

CUSTOM COMBI SET

MDR report key: 7082591 · Received December 5, 2017

Report

Report Number
8030665-2017-01069
Event Type
Malfunction
Date Received
December 5, 2017
Date of Event
November 21, 2017
Report Date
February 14, 2018
Manufacturer
ERIKA DE REYNOSA, S.A. DE C.V.
Product Code
FJK
UDI-DI
00840861100293
PMA / PMN Number
K962081
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CA, US
Reporter Occupation
HEALTH PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

COMMON DEVICE NAME: SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE. FDA PRODUCT CODE: FJK - SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE. A SUPPLEMENTAL MEDWATCH REPORT WILL BE SUBMITTED UPON COMPLETION OF THE INVESTIGATION.

Additional Manufacturer Narrative · 1

PLANT INVESTIGATION: ONE SAMPLE WAS RECEIVED FROM THE CUSTOMER WITHOUT ORIGINAL PACKAGE OR IDENTIFIED. DURING THE EVALUATION OF THE ACTUAL SAMPLE THE ALLEGED FAILURE WAS NOT CONFIRMED IN THE STATED COMPLAINT. THE VISUAL INSPECTION AND FUNCTIONAL TEST PASSED. DURING THE PERIOD TESTED NO AIR BUBBLES INSIDE THE SYSTEM, NO LEAKS AND NO LEVEL VARIATION OF VENOUS AND ARTERIAL CHAMBER OR ANY ALARM WERE NOTED. THE SAMPLE TESTED WORKED AS INTENDED WITHOUT ANY ABNORMALITIES DURING THE TESTED PERIOD. AN INVESTIGATION OF THE DEVICE MANUFACTURING RECORDS WAS CONDUCTED BY THE MANUFACTURER. THERE WAS NO INDICATION OF PRODUCT NON-ACCEPTANCE OR DEVIATION DURING THE MANUFACTURING PROCESS WHICH COULD BE ASSOCIATED WITH THE REPORTED EVENT. THE REVIEW INCLUDED A CHECK OF NON-CONFORMANCES, REWORK, LABELING, PROCESS CONTROLS, AND ANY OTHER OCCURRENCE IN PRODUCTION POTENTIALLY RELATED TO THE REPORTED COMPLAINT. THE LOT PASSED ALL RELEASE CRITERIA.

Additional Manufacturer Narrative · 1

CORRECTED EXPIRATION DATE: 2020-08-31 CORRECTED OCCUPATION: HEALTH CARE PROFESSIONAL PLANT INVESTIGATION: COMPLAINT SAMPLE IS NOT AVAILABLE FOR EVALUATION TO CONFIRM THE ALLEGED PRODUCT MALFUNCTION. A PRODUCTION RECORDS REVIEW WAS PERFORMED ON THE REPORTED LOT. AN INVESTIGATION OF THE DEVICE MANUFACTURING RECORDS WAS CONDUCTED BY THE MANUFACTURER. THERE WAS NO INDICATION OF PRODUCT NON-ACCEPTANCE OR DEVIATION DURING THE MANUFACTURING PROCESS WHICH COULD BE ASSOCIATED WITH THE REPORTED EVENT. THE REVIEW INCLUDED A CHECK OF NON-CONFORMANCES, REWORK, LABELING, PROCESS CONTROLS, AND ANY OTHER OCCURRENCE IN PRODUCTION POTENTIALLY RELATED TO THE REPORTED COMPLAINT. THE LOT PASSED ALL RELEASE CRITERIA.

Additional Manufacturer Narrative · 1

A SUPPLEMENTAL MEDWATCH REPORT WILL BE SUBMITTED UPON COMPLETION OF THE INVESTIGATION.

Description of Event or Problem · 1

A HEMODIALYSIS (HD) PATIENT'S CLINIC BIOMEDICAL ENGINEER (BIOMED TECH) REPORTED DURING HD TREATMENT THE TECHNICIAN NOTICED AIR IN BLOOD LINE APPROXIMATELY ONE MINUTE INTO TREATMENT. NO ALARM WAS NOTED. THE AIR WAS NOTED TO HAVE PASSED THE OCCLUSION CLAMP AROUND THE NEEDLE AREA. NO EXTERNAL LEAKS WERE NOTED. THE PATIENT WAS REMOVED FROM MACHINE AND BLOOD WAS NOT RETURNED TO PATIENT. THE PATIENT'S BLOOD LOSS WAS 300ML. THE HD PATIENT WAS UNABLE TO COMPLETE HD TREATMENT, WAS SENT TO THE EMERGENCY ROOM, EVALUATED AND RELEASED. THE PATIENT RETURNED TO THE CLINIC THE FOLLOWING DAY PER DOCTOR'S ORDER AND COMPLETED HD TREATMENT THE FOLLOWING DAY. THE ON-CALL PHYSICIAN REQUESTED THE MACHINE TO HAVE AIR DETECTOR RECALIBRATED AND AN OCCLUSION TEST WAS PERFORMED AND COMPLETED. THE SAMPLE WAS REPORTED TO HAVE BEEN AVAILABLE TO BE RETURNED FOR EVALUATION.

Description of Event or Problem · 1

A HEMODIALYSIS (HD) PATIENT'S CLINIC BIOMEDICAL ENGINEER (BIOMED TECH) REPORTED DURING HD TREATMENT THE TECHNICIAN NOTICED AIR IN BLOOD LINE APPROXIMATELY ONE MINUTE INTO TREATMENT. NO ALARM WAS NOTED. THE AIR WAS NOTED TO HAVE PASSED THE OCCLUSION CLAMP AROUND THE NEEDLE AREA. NO EXTERNAL LEAKS WERE NOTED. THE PATIENT WAS REMOVED FROM MACHINE AND BLOOD WAS NOT RETURNED TO PATIENT. THE PATIENT'S BLOOD LOSS WAS 300ML. THE HD PATIENT WAS UNABLE TO COMPLETE HD TREATMENT, WAS SENT TO THE EMERGENCY ROOM, EVALUATED AND RELEASED. THE PATIENT RETURNED TO THE CLINIC THE FOLLOWING DAY PER DOCTOR'S ORDER AND COMPLETED HD TREATMENT THE FOLLOWING DAY. THE ON-CALL PHYSICIAN REQUESTED THE MACHINE TO HAVE AIR DETECTOR RECALIBRATED AND AN OCCLUSION TEST WAS PERFORMED AND COMPLETED. THE SAMPLE WAS REPORTED TO HAVE BEEN AVAILABLE TO BE RETURNED FOR EVALUATION.

Description of Event or Problem · 1

A HEMODIALYSIS (HD) PATIENT'S CLINIC BIOMEDICAL ENGINEER (BIOMED TECH) REPORTED DURING HD TREATMENT THE TECHNICIAN NOTICED AIR IN BLOOD LINE APPROXIMATELY ONE MINUTE INTO TREATMENT. NO ALARM WAS NOTED. THE AIR WAS NOTED TO HAVE PASSED THE OCCLUSION CLAMP AROUND THE NEEDLE AREA. NO EXTERNAL LEAKS WERE NOTED. THE PATIENT WAS REMOVED FROM MACHINE AND BLOOD WAS NOT RETURNED TO PATIENT. THE PATIENT'S BLOOD LOSS WAS 300ML. THE HD PATIENT WAS UNABLE TO COMPLETE HD TREATMENT, WAS SENT TO THE EMERGENCY ROOM, EVALUATED AND RELEASED. THE PATIENT RETURNED TO THE CLINIC THE FOLLOWING DAY PER DOCTOR'S ORDER AND COMPLETED HD TREATMENT THE FOLLOWING DAY. THE ON-CALL PHYSICIAN REQUESTED THE MACHINE TO HAVE AIR DETECTOR RECALIBRATED AND AN OCCLUSION TEST WAS PERFORMED AND COMPLETED. THE SAMPLE WAS REPORTED TO HAVE BEEN AVAILABLE TO BE RETURNED FOR EVALUATION.

Description of Event or Problem · 1

A HEMODIALYSIS (HD) PATIENT'S CLINIC BIOMEDICAL ENGINEER (BIOMED TECH) REPORTED DURING HD TREATMENT THE TECHNICIAN NOTICED AIR IN BLOOD LINE APPROXIMATELY ONE MINUTE INTO TREATMENT. NO ALARM WAS NOTED. THE AIR WAS NOTED TO HAVE PASSED THE OCCLUSION CLAMP AROUND THE NEEDLE AREA. NO EXTERNAL LEAKS WERE NOTED. THE PATIENT WAS REMOVED FROM MACHINE AND BLOOD WAS NOT RETURNED TO PATIENT. THE PATIENT'S BLOOD LOSS WAS 300 ML. THE HD PATIENT WAS UNABLE TO COMPLETE HD TREATMENT, WAS SENT TO THE EMERGENCY ROOM, EVALUATED AND RELEASED. THE PATIENT RETURNED TO THE CLINIC THE FOLLOWING DAY PER DOCTOR'S ORDER AND COMPLETED HD TREATMENT THE FOLLOWING DAY. THE ON-CALL PHYSICIAN REQUESTED THE MACHINE TO HAVE AIR DETECTOR RECALIBRATED AND AN OCCLUSION TEST WAS PERFORMED AND COMPLETED. THE SAMPLE WAS REPORTED TO HAVE BEEN AVAILABLE TO BE RETURNED FOR EVALUATION.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
863867 CUSTOM COMBI SET SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE FJK ERIKA DE REYNOSA, S.A. DE C.V. 17KR01196 00840861100293

Patients

Seq Age Sex Outcome Treatment
1 26 YR