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 01/21/2015

Event Type  malfunction  

Event Description

The customer, a biomedical engineer, contacted physio-control to report that during a daily check of their device, they observed that a pin had broken off of a hard paddles assembly and become lodged in their device's therapy connector assembly.As a result, another set of hard paddles, or a quik-combo cable could not be installed and the device would not be able to provide defibrillation therapy, if it were necessary.There was no patient use associated with the reported event.

Manufacturer Narrative

(b)(4).The biomedical engineer advised that he was able to remove the broken pin from the device's therapy connector assembly which resolved the reported issue.The hard paddles with the broken pin were disposed of and a replacement set was obtained.After observing proper device operation through functional and performance testing the unit was placed back into service for use.Neither the device, nor the hard paddles assembly with the broken pin, have 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: 4542296
• MDR Text Key: 5541877
• Report Number: 3015876-2015-00216
• 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,Company Representative
• Reporter Occupation: Biomedical Engineer
• Type of Report: Initial
• Report Date: 01/29/2015

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/24/2015
• 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: 10 YR
• Event Location: Hospital
• Date Manufacturer Received: 01/29/2015
• Date Device Manufactured: 04/20/2005
• 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