ERIKA DE REYNOSA, S.A. DE C.V. CUSTOM COMBI SET; SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE
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Catalog Number 03-2722-9 |
Device Problem
Fluid/Blood Leak (1250)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 11/18/2018 |
Event Type
malfunction
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Manufacturer Narrative
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Plant investigation: as the device was not returned to the manufacturer, a physical evaluation could not be performed.A batch records review was conducted by the manufacturer for the reported lot.There were no non-conformances or abnormalities identified during the manufacturing process which could be associated with the reported event.The entire lot has been sold and distributed.In addition, a device history review was performed and confirmed that the results of the in-progress and final quality control (qc) testing met all requirements.The lot met all specifications for release.A product history review did not reveal a probable cause for the customer complaint.As a physical evaluation could not be performed, a definitive conclusion regarding the reported incident could not be reached and a cause could not be confirmed.
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Event Description
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A user facility clinic manager reported a blood leak observed at the connector between the venous pressure transducer and the fresenius combi set bloodlines.The blood leak occurred approximately 30 minutes into the patient¿s hemodialysis treatment.The clinic manager advised that the plastic used for the connector seemed more pliable than prior bloodlines, and noted that the connection appeared to loosen during use.The patient¿s estimated blood loss was 20ml, and they completed treatment on the same machine with new supplies.There was no injury, adverse event, or medical intervention required.The bloodlines were reportedly discarded and could not be returned.
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