CVR BASIC 3M STD CW DOM 8700-0001-807

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 99 report with the FDA on 2014-10-09 for CVR BASIC 3M STD CW DOM 8700-0001-807 manufactured by Ohio Medical Corporation.

Event Text Entries

[18872083] Complaint was received regarding device needing calibration. Upon return and service and repair investigation, it was noted that the diaphragm was torn. The device is a vacuum regulator intended to regulate suction to remove body fluids. It has been determined that a tear in the regulator diaphragm while in use (after vacuum has been set) could result in an increase in vacuum to the patient than what had been originally set.
Patient Sequence No: 1, Text Type: D, B5


[19126048] Device is a vacuum regulator. The device achieves its function via a regulator module that is equipped with a diaphragm. The user filed a complaint that the regulator needed calibration. During the investigation of the returned devices, it was discovered that the malfunctioning units had their diaphragms torn. The user did not report any patient involvement nor any adverse event. The user also did not file a form fda-3500a. The manufacturer is filing form fda-3500a because this was a malfunction that if it were to recur, it would have the potential to cause some patient harm. Investigation into the root cause in ongoing as of the date of this report and it has not yet been determined the extent to which remedial action would be appropriate to prevent an unreasonable risk of substantial harm to public health.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number1419185-2014-00018
MDR Report Key4181765
Report Source99
Date Received2014-10-09
Date of Report2014-10-09
Date of Event2014-09-04
Device Manufacturer Date2014-04-01
Date Added to Maude2014-10-22
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag0
Health Professional0
Initial Report to FDA3
Report to FDA0
Event Location0
Manufacturer Street1111 LAKESIDE DR.
Manufacturer CityGURNEE IL 60031
Manufacturer CountryUS
Manufacturer Postal60031
Manufacturer Phone8478556318
Single Use0
Remedial ActionRP
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameCVR BASIC 3M STD CW DOM
Generic NameVACUUM REGULATOR
Product CodeKDP
Date Received2014-10-09
Returned To Mfg2014-08-15
Model Number8700-0001-807
Lot NumberC3S143012
OperatorHEALTH PROFESSIONAL
Device AvailabilityR
Device Eval'ed by MfgrY
Device Sequence No1
Device Event Key0
ManufacturerOHIO MEDICAL CORPORATION
Manufacturer AddressGURNEE IL US


Patients

Patient NumberTreatmentOutcomeDate
10 2014-10-09

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