MAUDE Adverse Event Report: MASIMO - 15750 ALTON PKWY RD SET MP - 12; OXIMETER

Model Number 4083

Device Problem Sensing Intermittently (1558)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 10/01/2021

Event Type  malfunction  

Event Description

The customer reported the sensor was intermittent.No consequences or impact to patient were reported.

Manufacturer Narrative

Attempts have been made to obtain the product.The product has not been returned to masimo to allow an analysis to be performed.If the product is returned for evaluation or new information is obtained, a follow up report will be submitted.

Event Description

The customer reported the sensor was intermittent.No consequences or impact to patient were reported.

Manufacturer Narrative

Additional manufacturing narrative: the returned sensor was evaluated.During evaluation the sensor passed all visual and functional testing. the sensor was determined to be functioning as designed.

• Brand Name: RD SET MP - 12
• Type of Device: OXIMETER
• Manufacturer (Section D): MASIMO - 15750 ALTON PKWY; 15750 alton pkwy; irvine CA 92618
• Manufacturer (Section G): MASIMO - MEXICALI; industrial vallera de mexicali calzada del oro, no.2001; mexicali, baja california 21600 ; MX 21600
• Manufacturer Contact: matofa fautua ; 15750 alton pkwy; irvine, CA 92618 ; 9498223661
• MDR Report Key: 12919703
• MDR Text Key: 284986819
• Report Number: 3019388613-2021-00334
• Device Sequence Number: 1
• Product Code: DQA
• UDI-Device Identifier: 00843997009782
• UDI-Public: 00843997009782
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K050252
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Biomedical Engineer
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date: 11/08/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/02/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 4083
• Device Catalogue Number: 4083
• Device Lot Number: 20KDW
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/23/2021
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 12/09/2021
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 10/17/2020
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1