ERIKA DE REYNOSA, S.A. DE C.V. CUSTOM COMBI SET; SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE
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Model Number 03-2722-9 |
Device Problem
Fluid/Blood Leak (1250)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 10/07/2020 |
Event Type
malfunction
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Manufacturer Narrative
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Plant investigation: as the device was not returned to the manufacturer, a physical evaluation could not be performed.A batch records review was conducted by the manufacturer for the reported lot.There were no non-conformances or abnormalities identified during the manufacturing process which could be associated with the reported event.The entire lot has been sold and distributed.In addition, a device history review was performed and confirmed that the results of the in-progress and final quality control (qc) testing met all requirements.The lot met all specifications for release.A product history review did not reveal a probable cause for the customer complaint.As a physical evaluation could not be performed, a definitive conclusion regarding the reported incident could not be reached and a cause could not be confirmed.
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Event Description
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A user facility reported that a combi set blood leak occurred during a patient¿s hemodialysis (hd) treatment.Blood was observed dripping externally from the arterial side of the device, at the hard-red plastic ¿t¿ connector below the heparin line.There was no visible crack identified, and no line separation that occurred.No leaking was observed during the priming of the lines, and no machine alarms were reported.After the blood leak was seen, the treatment was halted.The patient¿s blood was not returned; estimated blood loss (ebl) was approximately 250 ml.Follow-up with the clinic¿s facility administrator (fa) confirmed there was no patient injury, no adverse effects were experienced, and no medical intervention was required as a result of the reported event.The patient completed their treatment after being re-setup with new supplies on a different machine.The combi set was not available to be returned for evaluation as it was reportedly discarded.
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