Model Number 0500318E |
Device Problem
Fluid/Blood Leak (1250)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 11/25/2021 |
Event Type
malfunction
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Event Description
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A registered nurse (rn) reported that a dialyzer blood leak occurred during a hemodialysis (hd) treatment.The blood leak was described as being at the venous head of the dialyzer.The leak was internal.The leak was visually observed.The machine alarmed appropriately with a blood leak alarm.The patient¿s estimated blood loss (ebl) was 250 ml.There was no patient injury, adverse events, or medical intervention required as a result of this event.The treatment was completed with another machine and new supplies.In a follow up it was reported that the event took place 19 minutes into the treatment.Blood test strips were not used.The machine was a 4008s clasica.The complaint device was discarded and is not available to be returned to the manufacturer for evaluation.
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Manufacturer Narrative
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The plant investigation is in process.A supplemental mdr will be submitted upon completion of this activity.
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Manufacturer Narrative
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Plant investigation: the reported complaint was not confirmed as the complaint device was not returned for manufacturer evaluation.A sample has not been provided for evaluation.The report could not be confirmed as a definitive conclusion regarding the complaint incident cannot be reached without a physical examination of the complaint sample.A review of the production record was performed.There was no indication of product non-acceptance or deviation in the manufacturing process related to the complaint event.This includes non-conformances, rework, labeling, process controls, and any other occurrence in production that was potentially related to the complaint.The reported lot number passed pyrogen testing, was within sterilization dosage parameters and passed all release criteria.There is no recall associated with this complaint.Continuous improvement is of the utmost importance to fresenius medical care as we strive to provide dialysis products of the highest quality to our patients.Reports of leaking product are investigated both individually as complaints, as well as via the nc/capa program in order to assess and improve our products and processes.Capas for vision systems and blood leak reduction are recent examples of leak related investigations directed at an overall reduction in dialyzer leaks.
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Event Description
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A registered nurse (rn) reported that a dialyzer blood leak occurred during a hemodialysis (hd) treatment.The blood leak was described as being at the venous head of the dialyzer.The leak was internal.The leak was visually observed.The machine alarmed appropriately with a blood leak alarm.The patient¿s estimated blood loss (ebl) was 250 ml.There was no patient injury, adverse events, or medical intervention required as a result of this event.The treatment was completed with another machine and new supplies.In a follow up it was reported that the event took place 19 minutes into the treatment.Blood test strips were not used.The machine was a 4008s clasica.The complaint device was discarded and is not available to be returned to the manufacturer for evaluation.
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Search Alerts/Recalls
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