MAUDE Adverse Event Report: PHYSIO-CONTROL, INC. - 3015876 LIFEPAK(R) 15 MONITOR/DEFIBRILLATOR; AUTOMATED EXTERNAL DEFIBRILLATORS (NON-WEARABLE)

Model Number	15
Medical Device Problem Code	Defibrillation/Stimulation Problem (1573)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/04/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Physio-control continues to investigate the reported issue and will submit a supplemental report on this event to the fda as provided by 21 cfr 803.56.
Event or Problem Description
The customer contacted physio-control to report that their device logged a critical event code.The event code is related to a potential issue of the device to deliver energy.The customer advised that when performing a test shock during preventative maintenance, the device screen went blank and froze for 7-10 seconds after delivering the shock.Upon powering up, the device service indicator was illuminated and the aforementioned event code was logged.On the device.There was no patient use associated with the reported event.
Event or Problem Description
The customer contacted physio-control to report that their device logged a critical event code.The event code is related to a potential issue of the device to deliver energy.The customer advised that when performing a test shock during preventative maintenance, the device screen went blank and froze for 7-10 seconds after delivering the shock.Upon powering up, the device service indicator was illuminated and the aforementioned event code was logged.On the device.There was no patient use associated with the reported event.
Additional Manufacturer Narrative
Physio-control evaluated the customer's device and verified the reported issue.The event code was not repeatable.Physio replaced the therapy pcb assembly as a precautionary measure.After observing proper device operation through functional and performance testing the device was returned to the customer for use.The cause of the reported issue could not be conclusively determined.

• Brand Name: LIFEPAK(R) 15 MONITOR/DEFIBRILLATOR
• Common Device Name: AUTOMATED EXTERNAL DEFIBRILLATORS (NON-WEARABLE)
• Manufacturer (Section D): PHYSIO-CONTROL, INC. - 3015876; 11811 willows road ne; redmond WA 98052
• MDR Report Key: 11042549
• Report Number: 0003015876-2020-01925
• Device Sequence Number: 11034713
• Product Code: MKJ
• UDI-Device Identifier: 00883873871638
• UDI-Public: 00883873871638
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• PMA/510(K) Number: K142430
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/10/2021

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 Model Number: 15
• Device Catalogue Number: 99577-001963
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/13/2021
• Initial Date Received by Manufacturer: 12/08/2020
• Supplement Date Received by Manufacturer: 08/18/2021
• Initial Report FDA Received Date: 12/18/2020
• Supplement Report FDA Received Date: 09/10/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1