MAUDE Adverse Event Report: ARJO HOSPITAL EQUIPMENT AB SYSTEM 2000; BATH, SITZ, POWERED

Model Number AR31811US1010

Device Problems Use of Device Problem (1670); No Apparent Adverse Event (3189)

Patient Problems Urinary Tract Infection (2120); No Consequences Or Impact To Patient (2199)

Event Type  Injury  

Manufacturer Narrative

(b)(4).The investigation is ongoing and further information will be provided in the next report.

Event Description

The customer facility has requested for verification of the system 2000 bath disinfectant system due to ongoing urinary tract infections (uti) issues with residents at this facility.Arjo representative visited the customer's site to verify the device functioning as per request.According to the results no disinfectant bottle was installed in the bath and a puddle of yellow liquid in the tub was found.Based on the received information the facility personnel did not use the arjo disinfectant system, but non-arjo disinfection liquid was utilized by pouring it in the bath.The arjo representative installed all-purpose cleanser and performed necessary adjustments.After service the device was tested and placed back in use.Arjo was not informed neither about any specific case of uti nor allegation that the arjo bath was source of the infection.Therefore, this report was submitted in abundance of caution.

Manufacturer Narrative

Please note that patient code and device code fields in section h.6 were corrected.The customer facility has requested verification of 5 arjo system 2000 baths and their disinfection systems due to ongoing urinary tract infections (uti) with residents at this facility.There was no allegation that the arjo bath was a source of the infection, also there was no microbiological test result nor other evidence provided.Arjo representative visited the customer's site to verify the device functioning as per request.Arjo representative visited the customer's site to verify the device functioning as per request.According to the results of technical evaluation performed for bath of serial number 1003000056, no disinfectant bottle was installed in the bath and a puddle of yellow liquid in the tub was found.Based on the received information the facility personnel did not use the arjo disinfectant system and not-arjo disinfection liquid was utilized by pouring it in the bath.The arjo representative installed arjo¿s all-purpose cleanser and performed necessary adjustments.After service, the device was tested and placed back in use.Considering the above, no relation between any infection case and arjo device was established.Moreover, arjo was not aware of any further information regarding customer investigation of the infection contributory factors.The device in question was equipped with a disinfection system, which according to the results of the evaluation was not used as intended.Equipment fitted with a bathtub disinfection device must be disinfected according to the instructions established in the operating and product care instructions.Please note that system 2000 operating and product care instructions (opci; 04.Ar.09_9 ¿ binding at the time this device was manufactured) provides user with the guidelines regarding proper performance of a disinfection procedure: ¿always make sure that: (¿) equipment is properly disinfected after each bath.¿ ¿make sure that there is an appropriate mixture of disinfectant liquid to the water by means of checking the flow meter.¿ the care and maintenance section of opci includes actions related to proper disinfection of device that shall be carried out in accordance with the preventive maintenance schedule on regular basis: ¿every day - cleaning/disinfection.Rhapsody/primo has to be cleaned immediately after use.Arjo cleaning agents and liquid treatment should be used in recommended concentrations.(¿)¿ ¿every month: - remove and clean the strainers in the shower heads (¿).Please note that this system 2000 unit was manufactured in 2010, so over 9 years before arjo received this complaint.Based on the performed analysis it was not possible to neither confirm the correlation between this bath and uti cases, nor to identify a potential root cause of their occurrence.According to our best knowledge, this type of infections can be caused by multiple factors and may origin from various sources.As per information collected to date, it appears likely that customer facility was not able to determine with absolute certainty the source of infections, hence took applicable actions - part of which was verification of the bath operation.Apart from these conclusions, it is considered likely that the device was not disinfected according to instructions.In summary, according to the gathered information the involved system 2000 bath was most probably used for patients hygiene, but no specific event was reported.Based on the performed evaluation of the device, it was functioning correctly and was performing according to the manufacturer specification, but was not properly used by the customer facility.There were 5 complaints reported in abundance of caution due to indication of ongoing uti (urinary tract infections) cases with residents at one customer facility, which potentially may be related to arjo devices.Five events have been reported under the following manufacturer report numbers: 3007420694-2020-00039, 3007420694-2020-00040, 3007420694-2020-00041, 3007420694-2020-00043 and 3007420694-2020-00042.

• Brand Name: SYSTEM 2000
• Type of Device: BATH, SITZ, POWERED
• Manufacturer (Section D): ARJO HOSPITAL EQUIPMENT AB; verkstadsvagen 5; eslov 24121 ; SW 24121
• MDR Report Key: 9749452
• MDR Text Key: 195458824
• Report Number: 3007420694-2020-00040
• Device Sequence Number: 1
• Product Code: ILM
• Combination Product (y/n): N
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,user f
• Type of Report: Initial,Followup
• Report Date: 03/25/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: No Information
• Device Model Number: AR31811US1010
• Was Device Available for Evaluation?: Yes
• Initial Date Manufacturer Received: 01/29/2020
• Initial Date FDA Received: 02/25/2020
• Supplement Dates Manufacturer Received: 01/29/2020
• Supplement Dates FDA Received: 03/25/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Other