OUTSET MEDICAL, INC. TABLO; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
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Device Problems
Energy Output Problem (1431); Unexpected Shutdown (4019)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 01/25/2022 |
Event Type
malfunction
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Event Description
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Stopping the crrt run on the pt.And preparing to return the blood to the pt.And the screen turned black and an unknown alert of "unfortunately, sequoia gui has stopped" and the machine shutdown, requiring the nurse to manually return the blood to the patient.The machine was taken down to the store room.There it was plugged in and connected to the water and the output drain.The screen on the machine indicated that the company should be called for service.I called the company and notified the representative of the event.He attempted to remote in and was unable to.He was still able to run reports.He instructed me to go ahead and run a heat clean.I set the pump for a heat clean.A case number of was assigned and i was instructed to tag the machine as out of service.I then emailed all the individuals that are attending the daily tablo touchbase meetings." i was on the phone with the representative for approximately 30 minutes with the machine.This did not take into account the time it took to get the machine down to the store room, hook it up and run the heat clean.If i had not been working, the charge nurse or other staff nurse would have had to deal with this and be off the floor for an extended period of time.
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Event Description
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Stopping the crrt run on the pt.And preparing to return the blood to the pt.And the screen turned black and an unknown alert of "unfortunately, sequoia gui has stopped" and the machine shutdown, requiring the nurse to manually return the blood to the patient.The machine was taken down to the store room.There it was plugged in and connected to the water and the output drain.The screen on the machine indicated that the company should be called for service.I called the company and notified the representative of the event.He attempted to remote in and was unable to.He was still able to run reports.He instructed me to go ahead and run a heat clean.I set the pump for a heat clean.A case number of was assigned and i was instructed to tag the machine as out of service.I then emailed all the individuals that are attending the daily tablo touchbase meetings." i was on the phone with the representative for approximately 30 minutes with the machine.This did not take into account the time it took to get the machine down to the store room, hook it up and run the heat clean.If i had not been working, the charge nurse or other staff nurse would have had to deal with this and be off the floor for an extended period of time.
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Event Description
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No equipment issues or human factors interacting with equipment identified.
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Search Alerts/Recalls
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