The rapid infuser involved in this incident has not been returned to belmont for investigation and we are therefore unable to confirm the reported system error #215 (real time clock watchdog alarm).When the rapid infuser detects a situation that is compromising effective infusing, the system stops pumping and heating, closes off the line to the patient, sounds an audible alarm, and displays an alarm message with instructions for corrective measure.The ri-2 system contains a watchdog that constantly monitors the flow of information back and forth between the power module and the computer.If the computer detects improper communication, the system stops pumping and heating and displays the error.No patient injury was reported.The manufacturing and service records for this serial number were reviewed and it was noted that this device was previously returned to belmont for the same issue in may 2019.The problem was traced to an improper software update by the distributor.The distributor was made aware of the improper maintenance and additional instructions were provided.Belmont has requested that this unit be returned to the manufacturer for further investigation.Additional training will be provided to the distributor if necessary.No trend has been identified for this type of issue.Should additional relevant information become available, a supplemental report will be provided.
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