Catalog Number 20350E-0006 |
Device Problem
Obstruction of Flow (2423)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/17/2023 |
Event Type
malfunction
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Manufacturer Narrative
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H3.A device evaluation is anticipated but has not yet begun.Upon completion of the investigation, a supplemental report will be filed.
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Event Description
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It was reported that bd alaris smartsite low sorbing extension set was occluded.The following information was received by the initial reporter with the verbatim: email received for customer informing bd of ?: faulty product as unable to prime extension set beyond filter.Customer reports that the acc dept has been using this filter set for years and it is both experienced and junior staff reporting the issues, so far nothing user error-related that they can see.Please see email for further information pir logged.
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Manufacturer Narrative
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D4: second lot number not included in initial submission, catalog #: 20350e-0006, lot #: 22119044, expiration date: 11/03/2025, manufacturing date: 11/18/2022.Investigation results: four 20350e-0006 samples were received for investigation; three samples were received in opened packaging from lot 22119318, and one sample was received in opened packaging from lot 22119044.Each of the sets were subjected to functional testing by attempting to prime the extension set; in three of the sets the customer's experience was confirmed with no fluid able to travel beyond the filter component (appendix 1-3).However in one the samples no fluid blockage or flow restriction was observed throughout testing.The details of this feedback were forwarded to the manufacturing site for investigation.Following a review of the manufacturing process, their analysis confirmed that the blockage was likely caused by an excess of solvent having been applied at the tubing joint of the filter during manufacture.This is a hand assembled joint and is likely to have occurred due to human error.A review of the production records for lot 22119318 & 22119044 did not identify any in-process testing failures or quality deviations which may have resulted in a report of this nature.The quality team at the manufacturing site has been informed of this report in order to be aware of the reported feedback during future production of this product.A review of the customer feedback database indicates that this is a rare occurrence with a small number of similar reports against the 20350e-0006 set in the past 12 months.
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Event Description
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No additional information.It was reported that bd alaris smartsite low sorbing extension set was occluded.The following information was received by the initial reporter with the verbatim: email received for customer informing bd of faulty product as unable to prime extension set beyond filter.Customer reports that the acc dept has been using this filter set for years and it is both experienced and junior staff reporting the issues, so far nothing user error-related that they can see.
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Search Alerts/Recalls
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