Model Number 61000 |
Device Problems
Use of Device Problem (1670); Inadequate User Interface (2958)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 07/24/2016 |
Event Type
malfunction
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Manufacturer Narrative
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Investigation is in process.A follow-up report will be provided.
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Event Description
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An internal investigation was performed of events in which an operator may have incorrectly entered patient data, creating an unreasonable body mass index (bmi).This event was identified during the internal investigation, not reported by the customer, therefore patient outcome is not available.This issue was identified internally.There was no adverse event reported, therefore, patient information is not reasonably known.Entered weight of patient: (b)(6) kg.Entered height of patient: 128 cm.Calculated bmi: 105.59.Protocol performed: red blood cell exchange (rbcx).
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Manufacturer Narrative
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This report is being filed to provide additional information.
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Event Description
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The customer stated that no adverse event occurred with this event and no medical intervention was required for this event.
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Manufacturer Narrative
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Investigation: the run data file (rdf) was reviewed for this run as part of an internal study.It was identified in the rdf that the patient weight and height may have been entered incorrectly, resulting in an unreasonable body mass index.Such a data entry error can lead to, in some instances, an over infusion of ac or a hypervolemic or hypovolemic condition if the error is not identified and corrected by the operator.There has been no indication that such an event did occur with this procedure.This issue was identified during an internal evaluation of available run data files.No on-site service was performed.One year of service history was reviewed for this device with no issues related to the reported condition identified.Terumo bct has followed up with this customer to provide feedback on the reported condition.Root cause: the root cause has been determined to be a user interface issue.Correction: optia field action 24 has been initiated to correct this issue by releasing a safety notification to all optia users to express the importance of entering the correct patient data and following the operator's manual and on-screen prompts.Corrective action: an internal capa has been initiated to address incorrect patient data entry.The field action referenced above will address this issue by updating all optia devices in the field to software version 11.3.This software version will allow the optia device to determine if entered patient height and weight combinations are feasible.
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Event Description
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The customer declined to provide patient information.Patient's gender and weight wereobtained from the run data file (rdf).
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Search Alerts/Recalls
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