MAUDE Adverse Event Report: MASIMO - 15750 ALTON PKWY EMMA (KPA) CAPNOGRAPH KIT; OXIMETER

Model Number 18266

Device Problem High Readings (2459)

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

Event Date 01/01/1901

Event Type  malfunction  

Manufacturer Narrative

Additional manufacturing narrative: attempts have been made to obtain the product.The product has not been returned to masimo to allow an analysis to be performed.If the product is returned for evaluation or new information is obtained, a follow up report will be submitted., other, other text: initial reporter phone # exceeded the maximum allowable characters, phone # is as follows: (b)(6).Initial reporter zip code exceeded the maximum allowable characters, zip code is as follows: (b)(6).

Event Description

The customer reported the device was measuring too high during a routine check.No patient impact or consequences were reported.

Manufacturer Narrative

Additional manufacturing narrative: the returned device was evaluated.Visual inspection found the optical detector lens was recessed.During accuracy testing, the unit measured outside of the specification.A zeroing calibration was performed and the following measured value was outside of accuracy specification.The recessed optical detector lens results in co2 measurements outside the accuracy specification.A service history record review reveals that this unit was in the field for over one (1) year with no previous reported issues related to this reported event.Initial reporter phone # exceeded the maximum allowable characters, phone # is as follows: (b)(6).Initial reporter zip code exceeded the maximum allowable characters, zip code is as follows: (b)(6).

Event Description

The customer reported the device was measuring too high during a routine check.No patient impact or consequences were reported.

• Brand Name: EMMA (KPA) CAPNOGRAPH KIT
• Type of Device: OXIMETER
• Manufacturer (Section D): MASIMO - 15750 ALTON PKWY; 15750 alton pkwy; irvine CA 92618
• Manufacturer (Section G): MASIMO - MEXICALI; industrial vallera de mexicali calzada del oro, no.2001; mexicali, baja california 21600 ; MX 21600
• Manufacturer Contact: matofa fautua ; 15750 alton pkwy; irvine, CA 92618 ; 9498223661
• MDR Report Key: 12677557
• MDR Text Key: 277982061
• Report Number: 3019388613-2021-00290
• Device Sequence Number: 1
• Product Code: CCK
• UDI-Device Identifier: 07350046131743
• UDI-Public: 07350046131743
• Combination Product (y/n): N
• Reporter Country Code: UK
• PMA/PMN Number: K063167
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,User Facility,Company Representative
• Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date: 09/27/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/21/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 18266
• Device Catalogue Number: 3678
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/05/2021
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/22/2021
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 01/09/2020
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1