CONCORD MANUFACTURING 2008T HEMODIALYSIS SYSTEM W/BIBAG; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
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Model Number 190766 |
Device Problems
Thermal Decomposition of Device (1071); Melted (1385)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 10/19/2021 |
Event Type
malfunction
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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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Event Description
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A biomedical technician (biomed) at a user facility reported that a fresenius 2008t hemodialysis (hd) machine had just completed cleaning and disinfection with bleach and a burning smell was noticed.Biomed stated that upon troubleshooting the machine issue, the valve 103 was found to be swollen and melted.Biomed did not observe any smoke, spark, flame, or arcing related to the swelling and melting found on the valve 103.Biomed stated that the machine has approximately 19,622 hours and that the valve is the original fresenius part on the machine.The machine has not had any past problems with failing the electrical leakage tests.The machine is always plugged into a hospital grade ground-fault circuit interrupter (gfci) outlet.Biomed stated that a circuit board from another unit was used during troubleshooting, which did not resolve the machine issue.Replacement valves are on order, therefore the machine is not back in service.Additionally, biomed confirmed that there was no damage observed on any other components, or any other additional issues, associated with the swollen and melted valve 103.Biomed confirmed that a patient was not connected to the machine at the time of the incident and there was no harm to any patients or individuals because of this malfunction.Biomed confirmed that the valve is available for return to the manufacturer for physical evaluation.
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Manufacturer Narrative
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Additional information: d9, h3 plant investigation: although it was stated that the complaint device was available to be returned, to date no parts were returned to the manufacturer for physical evaluation.Additionally, no on-site evaluation was performed by a fresenius field service technician (fst).A records review was performed on the reported serial number.An investigation of the device manufacturing records was conducted by the manufacturer.There were no non-conformances, or any associated rework identified during the manufacturing process which could be related to the reported event.In addition, the device history record (dhr) review confirmed the results of the in-progress and final quality control (qc) testing met all requirements.The investigation into the cause of the reported problem was not able to be confirmed.A definitive conclusion regarding the complaint incident cannot be reached without a physical examination of the complaint device.
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Event Description
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A biomedical technician (biomed) at a user facility reported that a fresenius 2008t hemodialysis (hd) machine had just completed cleaning and disinfection with bleach and a burning smell was noticed.Biomed stated that upon troubleshooting the machine issue, the valve 103 was found to be swollen and melted.Biomed did not observe any smoke, spark, flame, or arcing related to the swelling and melting found on the valve 103.Biomed stated that the machine has approximately 19,622 hours and that the valve is the original fresenius part on the machine.The machine has not had any past problems with failing the electrical leakage tests.The machine is always plugged into a hospital grade ground-fault circuit interrupter (gfci) outlet.Biomed stated that a circuit board from another unit was used during troubleshooting, which did not resolve the machine issue.Replacement valves are on order, therefore the machine is not back in service.Additionally, biomed confirmed that there was no damage observed on any other components, or any other additional issues, associated with the swollen and melted valve 103.Biomed confirmed that a patient was not connected to the machine at the time of the incident and there was no harm to any patients or individuals because of this malfunction.Biomed confirmed that the valve is available for return to the manufacturer for physical evaluation.
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