MAUDE Adverse Event Report: PERFUSION SYSTEMS "CONSOLE, RR5100052 RECON PCPB"; OXYGENATOR, CARDIOPULMONARY BYPASS

Model Number RR5100052

Device Problems Device Alarm System (1012); Power Problem (3010)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 10/26/2022

Event Type  malfunction  

Manufacturer Narrative

Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

Event Description

Medtronic received information that during use of a performer instrument, it was reported that the instrument shut off on it's own.It was also reported that there was a bad connection to the power entry and on reboot an error was displayed.The instrument was replaced to complete the procedure.There was no patient impact associated with this event.Medtronic received additional information that this instrument will be taken out of service.The customer has chosen not to have this unit repaired.The back-up will be put in it¿s place.Error code "a41 a041: bcl communication issue" displayed.It is unknown if a handcrank was used to maintain flow when the instrument change out occurred.

• Brand Name: "CONSOLE, RR5100052 RECON PCPB"
• Type of Device: OXYGENATOR, CARDIOPULMONARY BYPASS
• Manufacturer (Section D): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer (Section G): PERFUSION SYSTEMS; 7611 northland dr; brooklyn park MN 55428
• Manufacturer Contact: alison sweeney ; parkmore business park west; galway ; EI ; 091708096
• MDR Report Key: 15850614
• MDR Text Key: 307675434
• Report Number: 2184009-2022-00356
• Device Sequence Number: 1
• Product Code: DTZ
• UDI-Device Identifier: 00613994160638
• UDI-Public: 00613994160638
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K052555
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial
• Report Date: 11/23/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/23/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: RR5100052
• Device Catalogue Number: RR5100052
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 10/26/2022
• Date Device Manufactured: 10/22/2015
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1