MAUDE Adverse Event Report: TERUMO CORPORATION FX OXY W/RA & ART FILTER; BLOOD GAS OXYGENATOR

Model Number 1CX*FX25RE

Device Problem Disconnection (1171)

Patient Problem No Patient Involvement (2645)

Event Date 03/25/2014

Event Type  malfunction  

Event Description

The user facility reported to terumo cardiovascular systems that out of box the sampling line detached from the arterial side of the oxygenator.No patient involvement as this occurred out of box.

Manufacturer Narrative

Terumo has received the actual device for evaluation; however, the investigation has yet to be completed.Terumo plans on submitting a follow-up report when the investigation is complete and more information becomes available.For this reason, (b)(4).

• Brand Name: FX OXY W/RA & ART FILTER
• Type of Device: BLOOD GAS OXYGENATOR
• Manufacturer (Section D): TERUMO CORPORATION; 150 maimaigi-cho; prefecture 418; fujinomiya, shizuoka ; JA
• Manufacturer (Section G): TERUMO CORPORATION; ashitaka, 150; JA
• Manufacturer Contact: eileen dorsey, ra manager ; 125 blue ball road; elkton, MD 21921 ; 8002623304
• MDR Report Key: 3886302
• MDR Text Key: 4422825
• Report Number: 9681834-2014-00108
• Device Sequence Number: 1
• Product Code: DTZ
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K130520
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility,Company Representative
• Reporter Occupation: Not Applicable
• Type of Report: Initial
• Report Date: 03/25/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/09/2014
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Device Expiration Date: 04/30/2016
• Device Model Number: 1CX*FX25RE
• Device Lot Number: 130513
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 03/28/2014
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Device Age: 10 MO
• Event Location: Hospital
• Date Manufacturer Received: 03/25/2014
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/13/2013
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1