This report is being filed under exemption e2012066 by getinge (b)(4) co., ltd.(registration #3005619970) on behalf of the importer arjohuntleigh, inc.Ahus (registration #1419652).An investigation was carried out into this complaint.Arjohuntleigh was informed about an event which occurred during the therapy with alphaxcell system owned by the customer - caregivers of a quadriplegic patient noticed a pressure ulcer wound at patient's sacrum.The wound was treated by applying a compress/bandage.The stage of pressure ulcer was assessed as iii (serious injury).Patient's skin care was implemented, however, no service was requested to evaluate the alphaxcell system.The information about a pressure ulcer development was not forwarded to arjohuntleigh until 25 jun 2017, when the notification about a worsening condition of the patient was received.Arjohuntleigh decided to document and report this incident within two separate reports - pressure ulcer development and pressure ulcer worsening.When reviewing reportable events on alphaxcell system, arjohuntleigh found one similar event which occurred in the past with the involvement of the same alphaxcell system used with the same patient who developed a pressure ulcer stage 3.The affected system was returned to arjohuntleigh and comprehensive device evaluation was performed.Upon the inspection it was revealed that pump internal components (pivots, bellows, silencer bag and gearbox) required a repair.The malfunction of the pump resulted in air leakage within the system.Following the observation of the service engineer, the pressure in the system was about 8-10 mmhg which was still above the trigger for the low pressure alarm.Mattress was found in a very bad condition which was supported by photographic evidence - mattress loops (securing cells in place) were found severely damaged, with weldings split.Cells were likely to move out of their correct position, creating an extra space in between, especially when loaded.Consequently, due to empty spaces created by shifted cells, the patient was likely to get in contact with a bed frame, especially in the event of pressure loss.Worth to mention is a medical condition of the patient who was paralyzed, not able to experience discomfort or pain from the neck down.The therapy was performed in a homecare environment.The patient who has already had a history of pressure ulcers may be considered to be at a high risk of pressure injuries.According to the instruction for use # (b)(4), troubleshooting section, the user is advised to call service engineer for maintenance if the system is suspected not to work as intended.During the interview it was established that the instruction for use was available for users.The system was not under arjohuntleigh service contract but was serviced by arjohutnleigh upon request.It seems that symptoms of a soft mattress and visibly damaged loop sheet were ignored and the system was continued to be used until the pressure sore development.The malfunctioning system was in use for an unspecified period, but at least for a period of a few days (between pressure ulcer development notice and its worsening notice).This has exposed the patient already being at a high risk of pressure ulcers formation to a deterioration of health state.Following the conclusion of the investigation, it appears that the event of pressure ulcer development was a result of the following factors: condition of the involved mattress (damaged loops creating space between cells, allowing the patient to get in contact with a bed), air loss within the system which was still above the alarm triggering level, patient's medical condition (paralyzed patient in a homecare environment), ineffective procedure of patient's monitoring and product maintenance (damaged mattress left in use and no request for service until negative evolution of the injury).We are reporting this incident to competent authorities due to a serious outcome of the event.It has been established that alphaxcell system which was in use for a patient therapy at the time of the event has malfunctioned and contributed to the reported outcome.
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