MAUDE Adverse Event Report: NIHON KOHDEN CORPORATION ZM-521PA; TRANSMITTER

Model Number ZM-521PA

Device Problems Overheating of Device (1437); Temperature Problem (3022)

Patient Problems No Consequences Or Impact To Patient (2199); No Known Impact Or Consequence To Patient (2692)

Event Date 03/19/2019

Event Type  malfunction  

Manufacturer Narrative

The customer reported that there is heat damage on the lower right hand negative terminal.No consequence or impact to the patient was reported.The reported device was returned to nihon kohden; however, device evaluation anticipated, but not yet begun.Nihon kohden continues to investigate the reported event.Nihon kohden will submit a supplemental report in accordance with 21 cfr section 803.56 if additional information becomes available.

Event Description

The customer reported that there is heat damage on the lower right hand negative terminal.No consequence or impact to the patient.

Manufacturer Narrative

Corrected data: h3: device evaluated by manufacturer.H10: manufacturer narrative.Additional information: f7: type of report.G7: type of report.H2: if follow-up, what type.H6: event problem and evaluation codes.Manufacturer narrative: investigation result: the device warranty began 2016, which is over 2 years at the time of reported issue.There were no previously reported issues with the unit.Evaluation of the unit was unable to duplicate the overheating with the proper insertion of new batteries.Inspection of the right negative contact show plastic melting at the spring which per nkc investigation on a similar incident is indicative of improper battery insertion (nkc investigation report 2016 mdr 144/complaint (b)(4).Design controls in place for the potential hazards of improper battery insertion include: (1) spring was designed to not damage battery coating upon forcible battery insertion, (2) structure designed to protect battery pole from contact with battery spring when inserted in reversed direction, and (3) device designed to not cause over current in case of short-circuit damage from fall, etc.Additionally, measures to educate the customer on proper use of the batteries, including the recommended batteries, correct direction and insertion of battery, and on checking battery condition before use are addressed in the zm-521pa operator's manual.Customer is also advised to not allow the transmitter to continuously contact the patient's skin directly, as the transmitter heats up by 2 or 3 degrees c during normal operation, which may cause low temperature burn to the patient.Possible gradual deterioration of the transmitter battery compartment should be detected upon performance of the recommended maintenance check every six months, in which the customer is advised to ensure that the battery cover, springs, and terminals in the battery compartment are not damaged or corroded.Additionally, to highlight the importance of correct battery insertion, technical bulletins mtbex 047 issued (b)(6)17, mtbex 052 issued (b)(6)17, and mtbex 067 issues (b)(6)2018 were created which reiterate the recommendation of the operator's manual.Mtbex 047 provides step by step instruction's on how to properly insert the battery and mtbex 052 and mtbex 067 provide examples of correct and incorrect battery placement.Importance of proper battery insertion is also addressed through the zm telemeters skills lab offered at nk university.As the overheating could not be duplicated by the biomed or at nka, this issue is likely to have occurred due to improper insertion of the battery.The root cause is determined to be user error in improper insertion of the battery.The device was in use with a patient and there was no reported harm.

Manufacturer Narrative

Details of the complaint on (b)(6) 2019, (b)(6) at (b)(6) hospital reported there was heat damage on the lower right hand negative terminal of the transmitter zm-521pa sn:(b)(6).Investigation result: per nkc dhr , the unit has had no history of ncmr, deviation, or capa during manufacturing of the device.The device has not been refurbished and there were no discrepancies or unusual findings before device release that might relate to the reported issue.Qa evaluation of the unit at nka was unable to duplicate the overheating upon proper insertion of new batteries.Inspection of the negative contacts show dents in the plastic above the spring which per nkc investigation performed under (b)(4) on a similar incident is indicative of incorrect battery insertion.The incorrect insertion of the battery may cause the battery terminal spring to break the coating of the battery, leading to a short circuit.Measures to educate the customer on proper use of the batteries, including the recommended batteries, correct direction and insertion of battery, and on checking battery condition before use are addressed in the zm-520/530 series operator's manual.Customer is also advised to not allow the transmitter to continuously contact the patient's skin directly, as the transmitter heats up by 2 or 3 degrees c during normal operation, which may cause low temperature burn to the patient.Possible gradual deterioration of the transmitter battery compartment should be detected upon performance of the recommended maintenance check every six months, in which the customer is advised to ensure that the battery cover, springs, and terminals in the battery compartment are not damaged or corroded.To highlight the importance of correct battery insertion, technical bulletins mtbex 047 issued 02/09/17, mtbex 052 issued 04/25/17, and mtbex 067 issued 03/2018 were created which reiterate the recommendation of the operator's manual.Mtbex 047 provides step by step instructions on how to properly insert the battery and mtbex 052 and mtbex 067 provides examples of correct and incorrect battery placement.Importance of proper battery insertion is also addressed through the zm telemeters skills lab offered at nk university.Design considerations for the potential hazards of improper battery insertion/short circuit include: (1) spring was designed to not damage battery coating upon forcible battery insertion.(2) structure designed to protect battery pole from contact with battery spring when inserted in reversed direction.(3) device designed to not cause overcurrent in case of short-circuit damage from fall, etc.The root cause is determined to be transmitter design did not foresee possibility of short circuit from incorrect insertion of the battery.Nkc conducted a test study to monitor temperature of the transmitter upon incorrect insertion of the battery.The results confirmed that the temperature at the exterior is at an acceptable level and has cleared safety standard iec 60601-1.Per hha #19-009, there have been a total of 132 "overheated" related calls life-to-date until 03/07/19.The total number of devices in distribution is (b)(4) for the zm-520 series and (b)(4) for the zm-530 series.(b)(4).There have been no injuries or adverse patient events reported in association with the use of this device due to incorrect insertion of a battery.Assessment determined that in a worst case scenario, the probability of harm is "unlikely or remote" as the maximum exterior temperature (42.6 c) is below the minimum temperature (44 c) that can cause a burn after prolonged (greater than 5 hours) skin exposure.A new design change has been introduced to the transmitter rear case which would add an insulating sheet to prevent short circuit of the battery caused by incorrect battery insertion (see attached tn-1231).The design change has been applied to the following serial numbers: zm-520pa - serial (b)(6) or later.Zm-521pa - serial (b)(6) or later.Zm-530pa - serial (b)(6) or later.Zm-531pa - serial (b)(6) or later.Additionally, for transmitters with serial numbers prior to the implementation range, the updated part (#6142902693 for zm-520 series, #6142902694 for zm-530 series) is available for rear case repair.Investigation conclusion: the root cause of the heat damage is determined to be transmitter design did not foresee possibility of short circuit from incorrect insertion of the battery.Assessment determined that in a worst case scenario, the probability of harm is "unlikely or remote" as the maximum exterior temperature (42.6 c) is below the minimum temperature (44 c) that can cause a burn after prolonged (greater than 5 hours) skin exposure.A new design change has been introduced to the transmitter rear case which would add an insulating sheet to prevent short circuit of the battery caused by incorrect battery insertion.Corrected information: f9 approximate age of the device.Changed 42 months to the correct 41 months.

Event Description

The customer reported that there is heat damage on the lower right hand negative terminal.No consequence or impact to the patient.

• Brand Name: ZM-521PA
• Type of Device: TRANSMITTER
• Manufacturer (Section D): NIHON KOHDEN CORPORATION; 1-31-4 nishiochia, shinjuku-ku; attn: shama mooman; tokyo, 161-8 560; JA 161-8560
• MDR Report Key: 8509467
• MDR Text Key: 141771710
• Report Number: 8030229-2019-00092
• Device Sequence Number: 1
• Product Code: DRT
• UDI-Device Identifier: 04931921115084
• UDI-Public: 4931921115084
• Combination Product (y/n): N
• PMA/PMN Number: K043517
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional,user faci
• Type of Report: Initial,Followup,Followup
• Report Date: 01/29/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/12/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: ZM-521PA
• Device Catalogue Number: ZM-521PA
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/28/2019
• Was the Report Sent to FDA?: Yes
• Date Report Sent to FDA: 01/29/2020
• Distributor Facility Aware Date: 01/24/2020
• Device Age: 41 MO
• Event Location: Hospital
• Date Report to Manufacturer: 01/29/2020
• Date Manufacturer Received: 01/24/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Treatment: NA.