MAUDE Adverse Event Report: DRÄGERWERK AG & CO. KGAA PRIMUS; ANESTHESIA UNITS

Catalog Number 8603800

Device Problems Gas Output Problem (1266); Failure to Deliver (2338); Intermittent Communication Failure (4038)

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

Event Date 02/08/2022

Event Type  malfunction  

Event Description

It was reported that the device failed during use accompanied by a gas mixer failure alarm.Bagged patient and swapped out the unit.No patient consequences have been reported.

Manufacturer Narrative

The investigation was just started.The results will be forwarded in a follow-up report.

Manufacturer Narrative

The log file analysis revealed that during the case in question the device detected an internal communication error onboard a pcb that controls the communication between user interface, gas mixer and ventilator.The workstation initiated an emergency shutdown of automatic ventilation and posted corresponding alarms.Monitoring and manual ventilation remains possible in this state.The general issue is known from earlier occurrences of the same phenomenon.Intensive evaluation of the provided information and testing of concerned materials did not result in any finding.The fact that the involved pcb is used in another functional unit of the entire device without showing similar symptoms makes a design problem rather unlikely.A reasonable explanation would be emc disturbances beyond the immunity barriers of the workstation which is compliant to iec 60601-1-2.Therefore it is recommended that the conditions at the user facility should be checked to prevent from emc disturbance.The field failure rate of the affected pcb is accepted.

Event Description

It was reported that the device failed during use accompanied by a gas mixer failure alarm.Bagged patient and swapped out the unit.No patient consequences have been reported.

• Brand Name: PRIMUS
• Type of Device: ANESTHESIA UNITS
• Manufacturer (Section D): DRÄGERWERK AG & CO. KGAA; moislinger allee 53-55; lübeck ; GM
• Manufacturer (Section G): DRÄGERWERK AG & CO. KGAA; moislinger allee 53-55; lübeck 23542 ; GM 23542
• MDR Report Key: 13598240
• MDR Text Key: 289015581
• Report Number: 9611500-2022-00058
• Device Sequence Number: 1
• Product Code: BSZ
• Combination Product (y/n): N
• PMA/PMN Number: K042607
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 04/11/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/25/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 8603800
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 03/15/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 10/31/2004
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1