DURING A DIALYSATE CONVERSION, WE DISCOVERED ON (B)(6) 2009, THAT THE INCORRECT CONCENTRATE FAMILY HAD BEEN CHOSEN WHEN THE 2008H MACHINES WERE RE-CALIBRATED, BUT THE MACHINES WERE RUNNING WITHIN NORMAL LIMITS. THERE EXISTED A POTENTIAL TO HAVE EXPOSED PTS TO INCORRECT DIALYSATE LEVELS. WE RECEIVED ALL LABS AND HOSPITALIZATIONS AND FOUND THE FOLLOWING EVENTS MAY HAVE BEEN CAUSED OR EXACERBATED BY THE INCORRECTLY CALIBRATED MACHINES: ALL PATIENTS ADMITTED FOR FLUID OVERLOAD: PATIENT A: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT B: HOSPITALIZED ON (B)(6) 2000; DISCHARGED (B)(6) 2009. PATIENT C: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT D: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT E: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT F: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT G: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT H: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. PATIENT I: HOSPITALIZED ON (B)(6) 2009; DISCHARGED (B)(6) 2009. ON (B)(6) 2009, IMMEDIATELY UPON DISCOVERY OF THE INCORRECT CALIBRATIONS, THE H MACHINES WERE CORRECTED, CAUSING MINOR INTERRUPTIONS IN TREATMENT. AFTER THE MACHINES WERE CORRECTED, ALL THE MACHINES IN THE CLINIC WERE DOUBLE CHECKED BY THE CHIEF TECHNICAL OFFICER. BOTH TECHNICAL AND CLINICAL STAFF WERE RE-EDUCATED.
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Patient 1
(B)(4) - ADDRESSED IN DEVICE LABELING AS SERIOUS INJURY. (B)(4) - INCORRECT SETUP - ADDRESSED IN DEVICE LABELING. FROM UF REPORT: (B)(4) - ADDRESSED IN DEVICE LABELING AS HYPERVOLEMIA. CORRECTIVE ACTION WAS IMPLEMENTED AT THE FACILITY PRIOR TO THE MFR'S DEVICE INVESTIGATION. A FRESENIUS EQUIPMENT SPECIALIST VERIFIED THAT THE IMPLEMENTED CORRECTIVE ACTION ON THE MACHINES WERE DONE CORRECTLY. THE MACHINES ARE NOW SET CORRECTLY FOR THE TYPE OF CONCENTRATE BEING USED. THE FACILITY CONVERTED FROM ONE ACID CONCENTRATE TYPE (9000 SERIES OR 36.83X) TO ANOTHER TYPE (4000 SERIES OR 45X). AN EQUIPMENT TECH IMPROPERLY SET THE 2008H MACHINE FOR THE RESPECTIVE CONCENTRATE TYPE. THIS OPERATOR ERROR PREVENTED THE MACHINE FROM PROPERLY PROPORTIONING THE ACID AND BICARBONATE CONCENTRATE. THE MACHINE PROPORTIONS ACID AND BICARBONATE TO THE FINAL DIALYSATE CONCENTRATION, BASED ON A DEFINED DILUTION RATIO FOR THE GIVEN CONCENTRATE TYPE (36.83X VERSUS 45X). IN HOUSE TESTING, BY THE MFR, SIMULATING THE OPERATOR ERROR SHOWED THAT IMPROPERLY SETTING THE MACHINE TO ANOTHER CONCENTRATE TYPE COULD RESULT IN A NORMAL DILUTION OF SODIUM AND A BICARBONATE CONCENTRATION THAT IS APPROX 20% HIGHER THAN THE SET VALVE. THE 2008H OPERATOR'S MANUAL WARS THE OPERATOR TO "BE SURE TO USE COMPATIBLE CONCENTRATE TYPES, LABELING AND SET-UPS. THESE SETUPS INCLUDE MACHINE CALIBRATION, SPECIAL ADAPTERS FOR CERTAIN CONCENTRATE TYPES, CORRECT SETTING OF CONCENTRATE OPTION, AND LABELING. FAILURE TO USE THE PROPERLY MATCHED SOLUTIONS AND MACHINE CALIBRATIONS MAY ALLOW IMPROPER DIALYSATE TO THE PT, RESULTING IN PT INJURY OR DEATH. VERIFY COMPOSITION, CONDUCTIVITY, AND PH AFTER CONVERTING TO A DIFFERENT TYPE OF CONCENTRATE." THE CONVERSION TO OTHER DIALYSATE CONCENTRATE TYPES MUST BE DONE BY A QUALIFIED, AUTHORIZED PERSON ACCORDING TO WRITTEN PROCEDURES." "OPERATOR SHOULD ALWAYS CHECK CONDUCTIVITY AND APPROX PH OF THE DIALYSATE PRIOR TO INITIATING TREATMENT." (B)(4).