MAUDE Adverse Event Report: C.R. BARD, INC. (COVINGTON) -1018233 BARD® CRITICORE® MONITOR; CRITICORE MONITOR

Model Number 000002N

Device Problems Device Displays Incorrect Message (2591); Calibration Problem (2890)

Patient Problems No Consequences Or Impact To Patient (2199); No Known Impact Or Consequence To Patient (2692)

Event Type  malfunction  

Manufacturer Narrative

The investigation is still in progress.Once the investigation is complete a supplemental report will be filed.The information provided by bard represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bard.

Event Description

It was reported that as the unit was being used on a patient, the nurse noticed that device displayed 'check container'.The device displayed "not level" although the device was on a level surface.It was also noted that the device displayed '---' when the container volume key was pressed and the tank half full.

Manufacturer Narrative

The reported issue was confirmed.The root cause of the reported issue was determined to be the monitor being out of calibration for level / tilt.When the monitor read ¿not level¿ no fluid measurement was made, and there was no reading for the container volume.The monitor was calibrated which corrected the issue.Both hooks were bent and replaced.One handle cover and one arm cover were missing.There was a large crack on the front enclosure on the lower left bottom.The front enclosure, which includes the handle and arm assemblies was replaced.Both battery packs measured 4.05vdc and 4.03vdc, which was less than the 4.6vdc servicing minimum.The d cell batteries were replaced.Both battery housings have broken contacts and were replaced.The coin cell measured 2.957vdc which is less than the 3.00vdc minimum operating voltage and was replaced due to low voltage.The monitor was repaired, calibrated, passed all final tests and functions properly.The device history record was reviewed and found nothing that could have caused or contributed to the reported event.The instructions for use state the following: "warning: the criticore monitor requires special precautions regarding emc and needs to be installed and put into service according to the emc information provided in the following tables.Portable and mobile rf communications equipment may affect the criticore monitor.Warning: the criticore monitor should not be used adjacent to or stacked with other equipment and that if adjacent or stacked use is necessary, the criticore monitor should be observed to verify normal operation in the configuration in which it will be used.Warning: do not immerse or submerge the monitor or turn it upside down when cleaning.Caution: use only heavy-duty alkaline d cell batteries.Do not use rechargeable batteries.Do not incinerate batteries.Recycle or dispose of them properly.Contact bard for disposal information.Caution: improper orientation of the batteries within the battery pack can potentially damage the criticore monitor.Caution: state and federal regulations govern the packaging necessary for return of medical product which may have been contaminated.Refer to local, state and federal regulations when packaging the criticore monitor for return.Caution: there are no user serviceable components inside the criticore monitor.The user should not attempt to repair the criticore monitor.To do so may void the warranty and could result in erroneous monitor readings.Caution: use of cables or sensors other than those specified for use with the criticore monitor, except those sold by bard for use as replacement part or repair components, may result in increased emissions or decreased immunity of the criticore monitor.Caution: the criticore monitor should be recycled properly per european union directive 2002/96/ec on waste electronic and electrical equipment, january 27, 2003.Do not dispose with ordinary municipal waste.".

Event Description

It was reported that as the unit was being used on a patient, the nurse noticed that device displayed 'check container'.The device displayed "not level" although the device was on a level surface.It was also noted that the device displayed '---' when the container volume key was pressed and the tank half full.

• Brand Name: BARD® CRITICORE® MONITOR
• Type of Device: CRITICORE MONITOR
• Manufacturer (Section D): C.R. BARD, INC. (COVINGTON) -1018233; 8195 industrial blvd; covington GA 30014
• MDR Report Key: 7663436
• MDR Text Key: 113537189
• Report Number: 1018233-2018-02585
• Device Sequence Number: 1
• Product Code: EXS
• UDI-Device Identifier: 00801741080777
• UDI-Public: (01)00801741080777
• Combination Product (y/n): N
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: health professional,other,use
• Type of Report: Initial,Followup
• Report Date: 09/07/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 07/05/2018
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 000002N
• Device Catalogue Number: 000002N
• Device Lot Number: N/A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/15/2018
• Date Manufacturer Received: 08/14/2018
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1