MAUDE Adverse Event Report: CAREFUSION SD ALARIS SYSTEM; PUMP, INFUSION

Model Number 8210

Device Problems Device Alarm System (1012); Crack (1135); Communication or Transmission Problem (2896); No Apparent Adverse Event (3189)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 04/23/2021

Event Type  malfunction  

Manufacturer Narrative

The actual date of event is unknown.Device evaluated by bd service and not returned to manufacturing facility for evaluation.A review of the complaint history record was performed for the sn (b)(4) which did not confirm similar complaints with the same or related failure mode.A review of the device history record showed the device had a manufacture date of 28 apr 2007.The review was performed from the date of manufacture to the present date 28 apr 2021.A review of the device history record for sn (b)(4) was performed which confirmed that this device was not involved in a production failure which correlates to the customer reported issue.

Event Description

It was reported that the device displayed error code 200.405.There was no patient involvement.

Manufacturer Narrative

Correction: manufacturer narrative (dhr).Additional information: imdrf annex a, g, b, c and d grids and manufacturer narrative (shr).A review of the device history record showed the device had a manufacture date of 28apr2007.The review was performed from the date of manufacture to the present date 07jun2021.A review of the device history record for sn (b)(6) was performed which confirmed that this device was not involved in a production failure which correlates to the customer reported issue.A review of the service history record for sn (b)(6) was performed which confirmed that this device was not involved in a service failure which correlates to the customer reported issue.

Event Description

It was reported that the device displayed error code 200.405.There was no patient involvement.

• Brand Name: ALARIS SYSTEM
• Type of Device: PUMP, INFUSION
• Manufacturer (Section D): CAREFUSION SD; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 11818917
• MDR Text Key: 250431416
• Report Number: 2016493-2021-52334
• Device Sequence Number: 1
• Product Code: DQA
• UDI-Device Identifier: 10885403821011
• UDI-Public: (01)10885403821011
• Combination Product (y/n): N
• PMA/PMN Number: K010966
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,other
• Type of Report: Initial,Followup
• Report Date: 06/07/2021

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
• Device Operator: Other
• Device Model Number: 8210
• Device Catalogue Number: 8210 ALARIS SPO2 MODULE
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 04/23/2021
• Initial Date FDA Received: 05/13/2021
• Supplement Dates Manufacturer Received: 06/07/2021
• Supplement Dates FDA Received: 06/07/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1