MAUDE Adverse Event Report: CAREFUSION SD ALARIS SYSTEM; PUMP, INFUSION

Model Number 8120

Device Problems Pumping Stopped (1503); Insufficient Information (3190)

Patient Problem Pain (1994)

Event Date 11/08/2020

Event Type  malfunction  

Manufacturer Narrative

A follow up report will be submitted with investigation results should the device be repaired or the device/logs be received for evaluation.Per 803.52(f)(11)(iii) the information provided represents all of the known information at this time.The complainant or reporter was unable or unwilling to provide any further patient, product, or procedural details to the manufacturer.Device was not returned to manufacturing facility.

Event Description

A report was received from health canada's canada vigilance program which states, "pt was transferred from par just prior to evening shift change.Patient yelling out in pain, writer noticed that ketamine infusion channel was turned off but full ketamine syringe was inside chamber.Charge rn notified and verified as well.Total volume infused was zero.Charge rn and writer started ketamine infusion as per orders at 10mg/hr.".

Manufacturer Narrative

Additional information : imdrf annex a code.

Event Description

A report was received from health canada's canada vigilance program which states, "pt was transferred from par just prior to evening shift change.Patient yelling out in pain, writer noticed that ketamine infusion channel was turned off but full ketamine syringe was inside chamber.Charge rn notified and verified as well.Total volume infused was zero.Charge rn and writer started ketamine infusion as per orders at 10mg/hr.".

• Brand Name: ALARIS SYSTEM
• Type of Device: PUMP, INFUSION
• Manufacturer (Section D): CAREFUSION SD; 10020 pacific mesa blvd; san diego CA 92121 4386
• Manufacturer Contact: brett wilko ; 10020 pacific mesa blvd; san diego, CA 92121-4386 ; 8586172000
• MDR Report Key: 15475983
• MDR Text Key: 305988500
• Report Number: 2016493-2022-198442
• Device Sequence Number: 1
• Product Code: MEA
• Combination Product (y/n): N
• Reporter Country Code: CA
• PMA/PMN Number: K043299
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 10/21/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/24/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 8120
• Device Catalogue Number: 8120 ALARIS PCA MODULE
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 08/31/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Treatment: 8015