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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD VENTED HUMIDIFICATION CHAMBER; AUTOFEED CHAMBER

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FISHER & PAYKEL HEALTHCARE LTD VENTED HUMIDIFICATION CHAMBER; AUTOFEED CHAMBER Back to Search Results
Model Number MR290VX
Device Problems Crack (1135); Fluid/Blood Leak (1250); Leak/Splash (1354)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 08/26/2022
Event Type  malfunction  
Event Description
A healthcare facility in sweden via a fisher & paykel healthcare (f&p) field representative, that two mr290vx vented autofeed humidification chambers were found to be leaking during patient use.There was no patient consequence.
 
Manufacturer Narrative
(b)(4).The complaint mr290vx vented autofeed humidification chambers are currently en-route to fisher & paykel healthcare for evaluation.We will provide a follow up report upon completion of our investigation.
 
Manufacturer Narrative
(b)(4).Method: the complaint mr290v vented autofeed humidification chamber was returned to fisher & paykel healthcare (f&p) in new zealand where it was visually inspected and analysed.Results: visual inspection of the returned mr290v chamber revealed multiple horizontal crack lines were observed.The rolled base thickness were found to be within specification.Conclusion: we are unable to determine the root cause of the chamber crack, however our investigation indicates that the crack is most likely due to mechanical stress.The stress source was unable to be identified.The mr290 chambers are designed and tested to conform to iso 5367 breathing tubes intended for use with anaesthetic apparatus and ventilators.Every mr290 chamber is pressure tested following the manufacturing process to check for any leaks present in the chamber dome due to cracks and other causes.Any chamber which fails this test is rejected.In addition, the pressure test is followed by a visual inspection of each chamber.No cracks in the chamber dome are acceptable.Any chamber that fails this inspection is rejected.The subject mr290v chambers would have met the required specification at the time of production.Our user instructions that accompany the mr290v vented autofeed humidification chamber state the following: - "do not soak, wash, sterilize, or reuse this product.Avoid contact with chemicals, cleaning agents, or hand sanitizers." - "ensure appropriate ventilator or flow source alarms are set before connecting breathing set to patient." - "perform a pressure and leak test on the breathing system and check for occlusions before connecting to a patient." - "use of the mr290 above the maximum operating pressure may lead to cracking, water leakage and, on rare occasions, could lead to a loss of ventilation pressure" - "ensure there is water supply connected to the chamber and that water is present within the chamber" - "do not use the chamber if the seals are not intact when received, or if it has been dropped.".
 
Event Description
A healthcare facility in sweden via a fisher & paykel healthcare (f&p) field representative, that two mr290vx vented autofeed humidification chambers were found to be leaking during patient use.There was no patient consequence.
 
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Brand Name
VENTED HUMIDIFICATION CHAMBER
Type of Device
AUTOFEED CHAMBER
Manufacturer (Section D)
FISHER & PAYKEL HEALTHCARE LTD
15 maurice paykel place
east tamaki
auckland, 2013
NZ  2013
Manufacturer (Section G)
FISHER & PAYKEL HEALTHCARE LTD
15 maurice paykel place
east tamaki
auckland, 2013
NZ   2013
Manufacturer Contact
faranak gomarooni
17400 laguna canyon road
suite #300
irvine, CA 92618
9494534000
MDR Report Key15854058
MDR Text Key304343049
Report Number9611451-2022-00873
Device Sequence Number1
Product Code BTT
Combination Product (y/n)N
Reporter Country CodeSW
PMA/PMN Number
K934140
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Foreign,User Facility,Company Representative
Reporter Occupation Other
Type of Report Initial,Followup
Report Date 08/29/2022
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Model NumberMR290VX
Device Catalogue NumberMR290VX
Device Lot NumberNOT PROVIDED
Was Device Available for Evaluation? Device Returned to Manufacturer
Is the Reporter a Health Professional? No
Initial Date Manufacturer Received 08/29/2022
Initial Date FDA Received11/23/2022
Supplement Dates Manufacturer Received02/07/2023
Supplement Dates FDA Received02/14/2023
Was Device Evaluated by Manufacturer? Yes
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial
Patient Sequence Number1
Treatment
F&P RT330 INFANT OPTIFLOW TUBING KIT; F&P RT330 INFANT OPTIFLOW TUBING KIT
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