A hemodialysis (hd) user facility reported that a fresenius 2008t hd machine experienced a saline bag filling error and had high transmembrane pressure (tmp).
A fresenius field service technician (fst) was dispatched to the facility to evaluate the machine.
Additional details were revealed when the fst arrived onsite.
The clinic manager (cm) at the facility explained to the fst that the machine was set up incorrectly and the saline backfill was caused by use error.
The cm told the fst that one of the lines was left unclamped.
Per the cm, they changed the setup and it resolved the issue.
However, the tmp was still high.
It was confirmed that this occurred during priming; there was no patient involvement.
During testing, the fst could not duplicate the saline bag filling error or the high transmembrane pressure (tmp) problem.
As a precaution, the fst calibrated the dialysate pressure.
They also calibrated the bicarb pump and the concentrate pump.
The fst confirmed that the cbe upgrades had been completed on the machine, and that there were no reports of the machine giving any filling programs.
The fst said the machine was returned to service upon their departure, and they did not have any knowledge of there being further issues.
The saline bag filling error was caused by use error, and this was acknowledged by the reporting facility.
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