AMIA AUTOMATED PD CYCLER SET 5C5479

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,consum report with the FDA on 2020-03-27 for AMIA AUTOMATED PD CYCLER SET 5C5479 manufactured by Baxter Healthcare Corporation.

Event Text Entries

[185478829] Therapy date - this events occurred approximately a week prior to the date and on (b)(6)2020. The devices were not returned and the lot number is unknown; therefore, a device analysis could not be completed. Should additional relevant information become available, a supplemental report will be submitted.
Patient Sequence No: 1, Text Type: N, H10


[185478830] It was reported that two (2) amia automated pd cycler sets leaked during dwell two of peritoneal dialysis therapy. The patient was connected at the time of the event. It was further reported that solution was leaking from the cycler door; however, the patient was unable to identify the exact source of the leak. There was no damage noted on the supplies. There was no patient injury or medical intervention associated with this event. No additional information is available.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number1416980-2020-01803
MDR Report Key9891490
Report SourceCOMPANY REPRESENTATIVE,CONSUM
Date Received2020-03-27
Date of Report2020-03-24
Date Mfgr Received2020-03-01
Date Added to Maude2020-03-27
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer Street25212 W. ILLINOIS ROUTE 120
Manufacturer CityROUND LAKE IL 60073
Manufacturer CountryUS
Manufacturer Postal60073
Manufacturer Phone2242702068
Manufacturer G1BAXTER HEALTHCARE - MOUNTAIN HOME
Manufacturer Street1900 N HIGHWAY 201
Manufacturer CityMOUNTAIN HOME AR 72653
Manufacturer CountryUS
Manufacturer Postal Code72653
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameAMIA AUTOMATED PD CYCLER SET
Generic NameSYSTEM, PERITONEAL, AUTOMATIC DELIVERY
Product CodeFKX
Date Received2020-03-27
Model NumberNA
Catalog Number5C5479
Lot NumberASKU
OperatorLAY USER/PATIENT
Device AvailabilityN
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerBAXTER HEALTHCARE CORPORATION
Manufacturer AddressDEERFIELD IL


Patients

Patient NumberTreatmentOutcomeDate
10 2020-03-27

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