MAUDE Adverse Event Report: PHYSIO-CONTROL, INC LIFEPAK(R) 12 DEFIBRILLATOR/MONITOR SERIES; DEFIBRILLATORS, AUTOMATIC, EXTERNAL

Catalog Number VLP12-02B

Device Problem Material Fragmentation (1261)

Patient Problem No Patient Involvement (2645)

Event Date 06/06/2014

Event Type  malfunction  

Event Description

The customer, a biomedical engineer, contacted physio-control to report that a pin from a quik-combo therapy cable had broken off and become lodged in their device's therapy connector assembly.This issue could prevent defibrillation therapy from being delivered, if necessary.There was no patient use associated with the reported event.

Manufacturer Narrative

(b)(4): physio-control provided the biomedical engineer with technical assistance and the part number for replacement therapy connector and quik combo therapy cable assemblies.It was later confirmed by the biomed that they will be replacing the therapy connector and quik combo therapy cable assemblies on the device.After observing proper device operation through functional and performance testing the unit will be placed back into service for use.The device has not been returned to physio-control for evaluation.

• Brand Name: LIFEPAK(R) 12 DEFIBRILLATOR/MONITOR SERIES
• Type of Device: DEFIBRILLATORS, AUTOMATIC, EXTERNAL
• Manufacturer (Section D): PHYSIO-CONTROL, INC; 11811 willows road ne; po box 97006; redmond WA 98073 970
• Manufacturer (Section G): PHYSIO-CONTROL, INC; 11811 willows road ne; po box 97006; redmond WA 98073 970
• Manufacturer Contact: jason march ; 4258674000
• MDR Report Key: 3903298
• MDR Text Key: 4544494
• Report Number: 3015876-2014-00744
• Device Sequence Number: 1
• Product Code: MKJ
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K102972
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional,User Facility
• Reporter Occupation: Biomedical Engineer
• Type of Report: Initial
• Report Date: 06/06/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/30/2014
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: VLP12-02B
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Device Age: 13 YR
• Event Location: Hospital
• Date Manufacturer Received: 06/06/2014
• Date Device Manufactured: 04/21/2001
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1