MAUDE Adverse Event Report: OREGON MANUFACTURING PLANT NATURALYTE 2301 2K 3.0CA 1MG GAL; DIALYSATE CONCENTRATE FOR HEMODIALYSIS (LIQUID OR POWDER)

Model Number	08-2301-3
Medical Device Problem Code	Chemical Problem (2893)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	10/21/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Plant investigation: the customer reported the sample was available for return, however, as of 11/12/2020, no samples were returned.Samples are not needed to confirm the allegation.A sample retain was tested through a special test request, and found to be within specifications.In addition, there were companion samples available for testing which were tested at both the (b)(6) laboratories, and results were found to be conflicting.Due to the conflicting results found between the laboratories, the (b)(4)test methods were reviewed, and a deficiency was found in the test method pertaining to the sodium and potassium analyte tests.Because of the deficiency found in the test method, it was determined that lot#: 20lxac056 did not meet release specifications, and the allegation conductivity low was confirmed.A product history review was performed.A review of the complaint management system on 11/13/2020 identified 13 additional reported events for lot no.: 20lxac056 related to conductivity issues.The threshold for non-conformance was reached for lot#: 20lxac056, however, a non-conformance was already initiated for this issue.A review of the product inventory records for lot no.: 20lxac056 indicated that 2241 cases of finished product were manufactured on 9/16/20 for distribution with no additional noted nonconformances.After reviewing the finished product release summary, it was determined that 20lxac056 met release specifications.In conclusion, 20lxac056 release testing was found to be compromised due to the deficient test method.A non-conformance was already opened for allegations of conductivity issues and escalated to a corrective action preventative action (capa).Based on the investigation performed, cause was traced to manufacturing.
Event or Problem Description
A hemodialysis (hd) clinic biomedical technician (biomed) reported that some naturalyte had low conductivity.Upon follow up, the customer said that before use, the conductivity was at 12.9ms/cm.The theoretical conductivity value (tcd) setting on the machine was not provided, and the difference between actual conductivity is unknown.The biomed stated that six and a half cases are affected.The product was used for patient treatment without conductivity issues.There was no patient adverse event.The biomed reported that the machines have had product maintenance, but no other service to any of the machines.The biomed stated they used naturalyte with lot number 20dxac106 successfully with no further issues.The facility was using bicarbonate bibag 400rx12; lot#: 20kxbc004.A return goods authorization (rga) was issued to the clinic for product return.

• Brand Name: NATURALYTE 2301 2K 3.0CA 1MG GAL
• Common Device Name: DIALYSATE CONCENTRATE FOR HEMODIALYSIS (LIQUID OR POWDER)
• Manufacturer (Section D): OREGON MANUFACTURING PLANT; director, quality systems; 750 n lallendorf road; oregon OH 43616
• MDR Report Key: 10925929
• Report Number: 3005162618-2020-00106
• Device Sequence Number: 2469818
• Product Code: KPO
• UDI-Device Identifier: 00840861101702
• UDI-Public: 00840861101702
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K192017
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Biomedical Engineer
• Type of Report: Initial
• Report Date (Section B): 12/01/2020

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
• Operator of Device: Health Professional
• Device Expiration Date: 09/30/2022
• Device Model Number: 08-2301-3
• Device Catalogue Number: 08-2301-3
• Device Lot Number: 20LXAC056
• Was Device Available for Evaluation?: No
• Device Age: MO
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/06/2020
• Initial Report FDA Received Date: 12/01/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1