MAUDE MDR 5248525

MDR report key
5248525
Report number
2021710-2015-02323
Event key
0
Event type
3
Date of event
2015-11-02
Date received
2015-11-24
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
100
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
JILL RITTORNO
Address
75 N. FAIRWAY DRIVE VERNON HILLS IL 60061 US
Phone
847-847-8473
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1STATIC AND DYNAMIC COMPLIANCECALCULATOR, PREDICTED VALUES, PULMONARY FUNCTIONCAREFUSIONBTY22 E777543-102R Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12015-11-240

Event Narratives#

N

Patient 1

THE FIELD SERVICE ENGINEER (FSE) ASSESSED THE UNIT AND NOTED THE ANALYZER RESPONDED INCORRECTLY TO GAS CALIBRATION AND VERIFIED GAS TANK PRESSURES. THE FSE DISCOVERED A FAULTY OXYGEN (O2) CELL SENSOR AND REPLACED THE SENOR TO RESOLVE THE REPORTED ISSUE. THE FSE THEN ALLOWED THE UNIT TO WARM UP AND RE-VERIFIED ALL O2 RESPONSES RETURNED TO NORMAL RANGES. THE FSE PERFORMED A FUNCTIONAL RESIDUAL CAPACITY (FRC) CALIBRATION AND IT PASSED WITHIN SPECIFICATIONS. AN FRC VALIDATION PROCEDURE WAS ALSO PERFORMED AND COMPLETED AT 98% OF TARGET. THE CUSTOMER INDICATED THE QUESTIONED DEVICE WILL NOT BE RETURNED TO CAREFUSION. THE UNIT WAS RETURNED TO NORMAL OPERATION. NO FURTHER ISSUES WERE NOTED BY THE CUSTOMER. (B)(4). IN CONCLUSION, THE LIKELY CAUSE OF THE EVENT IS ATTRIBUTED TO THE O2 CELL SENSOR. HOWEVER, A DEFINITIVE ROOT CAUSE IS UNKNOWN WITH THE AVAILABLE INFORMATION. CAREFUSION CONTINUES TO TRACK AND TREND ANY INCIDENT RELATED TO THIS ISSUE.

D

Patient 1

THE CUSTOMER REPORTED GAS CALIBRATION ISSUE WHILE USING THE VMAX ENCORE 22 PULMONARY FUNCTION ANALYSIS INSTRUMENT. A PATIENT WAS BEING TESTED AT THE TIME OF THE REPORTED ISSUE, AND TEST RESULTS WERE GENERATED AND RELEASED TO THE PHYSICIAN. THE CUSTOMER THEN NOTICED THE RESULTS WERE ERRONEOUS AND INFORMED THE PHYSICIAN; THE RESULTS WERE NOT USED IN MAKING A DIAGNOSIS. THE CUSTOMER STATED THERE WAS NO PATIENT IMPACT ASSOCIATED WITH THIS EVENT. A FIELD SERVICE ENGINEER (FSE) WAS DISPATCHED TO ASSESS INSTRUMENT.

N

Patient 1

ADDITIONAL INFORMATION FROM FIELD SERVICE: THE FIELD SERVICE ENGINEER (FSE) VERIFIED THE ISSUE WITH O2 CELL - READING AT 0.100 WITH THE PUMP ON. THE FSE REMOVED THE FAULTY O2 CELL AND INSTALLED A NEW O2 CELL. THE FSE ALLOWED THE UNIT TO WARM UP THEN PERFORMED VERIFICATIONS - ALL O2 RESPONSES RETURNED TO NORMAL. THE FSE PERFORMED FUNCTIONAL RESIDUAL CAPACITY (FRC) ANALYZER CALIBRATION AND IT PASSED MULTIPLE TIMES. THE FSE PERFORMED FRC VALIDATION PROCEDURE AND IT WAS 98% OF TARGET.

N

Patient 1

DEVICE EVALUATION: AN EVALUATION OF THE RETURNED DEVICE WAS PERFORMED. VISUAL INSPECTION OF THE RECEIVED O2 ANALYZER ASSEMBLY NOTED NO ISSUES. THE SERVICE TECHNICIAN CONNECTED THE O2 ANALYZER TO A KNOWN GOOD VMAX TEST UNIT AND NOTED THE O2 READING DID NOT CHANGE AFTER O2 WAS SUPPLIED. THE TECHNICIAN CONFIRMED IT FAILED THE ANALYZER CALIBRATION PER LUNG VOLUMES TEST, PER THE MANUFACTURING PROCEDURE. THE REPORTED ISSUE WAS ABLE TO BE DUPLICATED. IN CONCLUSION, THE LIKELY CAUSE OF THE EVENT IS ATTRIBUTED TO THE O2 ANALYZER ASSEMBLY. HOWEVER, A DEFINITIVE ROOT CAUSE IS UNKNOWN. CAREFUSION CONTINUES TO TRACK AND TREND ANY INCIDENT RELATED TO THIS ISSUE.