MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05,06 report with the FDA on 2014-10-24 for SIEMENS MED-RO SYSTEM US FILTER MED RO manufactured by Mar Cor Purification.
[5040841]
Mar cor purification received a letter from the customer on 9/24/2014 regarding high endotoxin/bacteria readings post di (deionized) tanks on (b)(6) 2014. Seven patients were treated with di water produced from these di tanks. The clinic reviewed all patient charts and no patient issues were noted.
Patient Sequence No: 1, Text Type: D, B5
[12493320]
Mar cor delivered di tanks to the customer in august/september of 2013 as standby tanks in case their central reverse osmosis (ro) went down. January 2014 a di cart was delivered to the customer to be used with the standby tanks. (b)(6) the customer's siemens central ro system alarmed due to high total dissolved solids (tds). Two patients were removed from treatment and 3 patients had treatment delayed. The di tanks were installed by the customer to be used while the ro system was being repaired. Endotoxin samples of the product water were taken and sent for testing. (b)(6) 2014 the water sample test results tested high for bacteria and endotoxin; 61. 00 eu/ml and the aami standard is less than 2. 0 eu/ml. The clinic believed the di tanks were not delivered in a ready to use state. Upon investigation, it was determined the customer did not have the necessary pyrogen filter installed post di per aami/cms standards. Per cms regulation v202, ansi/aami rd52:2004 5. 2. 8 interpretive guidance: water treated by di may be very high quality with regard to the absence of ionized contaminants, but the process does not remove nonionized substances, including bacteria and bacterial endotoxins... Deionizers are an effective means of removing ionic contaminants from water. However, they do not remove nonionic species (such as bacteria), and they may contribute bacterial contaminants to the water... Deionizers offer a large surface area for bacterial proliferation and deionizers generally contribute to the bioburden in the water. The tendency for deionizers to contribute bacterial contaminants to the water is greater when deionizers are kept as a backup for a reverse osmosis system. Cms regulation v204, ansi/aami rd52:2004 5. 2. 8 states: in all instances, deionizers shall be followed by an ultrafilter or other bacteria- and endotoxin-reducing device to remove microbiological contaminants that may originate in the deionizer resin bed. Seven patients were treated with product water high in bacteria and endotoxins. The customer initiated a multidisciplinary team which reviewed all patient charts. No patient issues were noted. There were no reports of patient illness or injury as a result of this incident. This complaint will continue to be maintained within mar cor purification's complaint system.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 3019131-2014-00030 |
| MDR Report Key | 4200693 |
| Report Source | 05,06 |
| Date Received | 2014-10-24 |
| Date of Report | 2014-10-24 |
| Date of Event | 2014-03-28 |
| Date Mfgr Received | 2014-09-24 |
| Date Added to Maude | 2014-10-24 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | MEGAN DICKEY |
| Manufacturer Street | 14550 28TH AVE N |
| Manufacturer City | MINNEAPOLIS MN 55447 |
| Manufacturer Country | US |
| Manufacturer Postal | 55447 |
| Manufacturer Phone | 7635533300 |
| Manufacturer G1 | MAR COR PURIFICATION |
| Manufacturer Street | 14550 28TH AVE N |
| Manufacturer City | MINNEAPOLIS MN 55447 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 55447 |
| Single Use | 3 |
| Remedial Action | OT |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | SIEMENS MED-RO SYSTEM |
| Generic Name | CENTRAL WATER TREATMENT SYSTEM |
| Product Code | FIP |
| Date Received | 2014-10-24 |
| Model Number | US FILTER MED RO |
| ID Number | 095-15-126 |
| Operator | OTHER |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | MAR COR PURIFICATION |
| Manufacturer Address | 14550 28TH AVE N MINNEAPOLIS MN 55447 US 55447 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2014-10-24 |