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Model Number 470108 |
Device Problem
Fluid/Blood Leak (1250)
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Patient Problems
Blood Loss (2597); No Known Impact Or Consequence To Patient (2692)
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Event Type
malfunction
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Manufacturer Narrative
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This report has been identified as b.Braun medical internal report number (b)(4).The device involved has not been received for evaluation and the investigation is ongoing at this time.A follow up will be submitted when the investigation results become available.
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Event Description
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As reported by the user facility: during the first 15 minutes of the blood transfusion, no abnormalities were noted.However, 30 minutes later, the product leaked.Blood was observed at the anti-reflux valve.The transfusion was stopped, the device was changed, and the transfusion was resumed without issues.
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Manufacturer Narrative
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This report has been identified as b.Braun medical internal report number (b)(4).One (1) used sample without packaging was returned for evaluation.Visual examination of the sample noted that a luer connector was broken off inside the caresite valve.Based on the evaluation of the sample the reported defect is confirmed.Although the exact root cause cannot be determined, previous engineering testing cited a probable root cause could be alcohol exposure of certain male adapters, which can lead to difficulty removing or breakage of male luer tapers when connected to female luers.Per the ifu, "swab top lad vigorously for 15 seconds with 70% isopropyl alcohol and allow to air dry prior to use." please note the air drying of the alcohol prior to use.We will maintain this report for further references and continue to monitor other reports for similar occurrences.If any additional pertinent information becomes available, a follow up will be submitted.
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Search Alerts/Recalls
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