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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: OUTSET MEDICAL, INC. TABLO(R) HEMODIALYSIS SYSTEM DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM

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OUTSET MEDICAL, INC. TABLO(R) HEMODIALYSIS SYSTEM DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM Back to Search Results
Device Problem Contamination (1120)
Patient Problem Bacterial Infection (1735)
Event Date 01/13/2022
Event Type  malfunction  
Event Description
Patient had positive blood culture while on dialysis treatment. Three dialysis patients from medical icu were reported to have central line-associated bloodstream infections. A deeper look into this identified an association between the patients and the tablo device ((b)(4)). The device was used for treatment for a 2-week period. Patients all had positive blood cultures after they received dialysis from the device. Recommend: review disinfectant logs and lab reports for machine. Look to see if there is a trend with positive blood cultures and dialysis. Investigate machine for mechanical failures that would lead to contamination.
 
Event Description
Patient had positive blood culture while on dialysis treatment. Three dialysis patients from medical icu were reported to have central line-associated bloodstream infections. A deeper look into this identified an association between the patients and the tablo device. The device was used for treatment for a 2-week period. Patients all had positive blood cultures after they received dialysis from the device. Recommend: review disinfectant logs and lab reports for machine. Look to see if there is a trend with positive blood cultures and dialysis. Investigate machine for mechanical failures that would lead to contamination.
 
Event Description
No equipment issues or human factors interacting with equipment identified.
 
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Brand NameTABLO(R) HEMODIALYSIS SYSTEM
Type of DeviceDIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
Manufacturer (Section D)
OUTSET MEDICAL, INC.
3052 orchard drive
san jose CA 95134
MDR Report Key13839287
MDR Text Key287548628
Report Number13839287
Device Sequence Number1
Product Code KDI
Combination Product (y/n)N
Number of Events Reported1
Summary Report (Y/N)N
Report Source User Facility
Reporter Occupation Other Health Care Professional
Type of Report Initial,Followup,Followup
Report Date 02/15/2022
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received03/21/2022
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Was Device Available for Evaluation? Yes
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA? Yes
Date Report Sent to FDA02/15/2022
Device Age4 MO
Event Location Hospital
Date Report to Manufacturer03/21/2022
Was Device Evaluated by Manufacturer? No Answer Provided
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Unkown

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