[20437487]
4/28/92 floor nurse called maintenance-reported the redy 2000 had a malfunction. Bio-med technician responded and reported lowflow alarms during priming mode. Called manufacturer and reported malfunction. 4/29/92 organon-teknika field engineer came and replaced flow transducer and checked out system. Patient was an 85 year old white female who was hospitalized with chf and renal failure. Dialysis machine would not function out of priming mode. Patient ultimately transferred to another facility for dialysisdevice not labeled for single use. Patient medical status prior to event: critical condition. There was not multiple patient involvement. Device serviced in accordance with service schedule. Date last serviced: 01-apr-92. Service provided by: manufacturer. Service records available. No imminent hazard to public health claimed. Device used as labeled/intended. Device was evaluated after the event. Method of evaluation: actual device involved in incident was evaluated, mechanical tests performed, performance tests performed. Results of evaluation: component failure, transducer. Conclusion: invalid data. Certainty of device as cause of or contributor to event: invalid data. Corrective actions: device repaired and put back in service. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5