MAUDE Adverse Event Report: MASIMO - 15750 ALTON PKWY ISA OR+ KIT; OXIMETER

Model Number 37393

Device Problem High Readings (2459)

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

Event Date 03/04/2022

Event Type  malfunction  

Manufacturer Narrative

Additional manufacturing narrative: attempts have been made to obtain the product.The product has not been returned to masimo to allow an analysis to be performed.If the product is returned for evaluation or new information is obtained, a follow up report will be submitted., other, other text: initial reporter zip code exceeded the maximum allowable characters, zip code is as follows: (b)(6).

Event Description

The customer reported the isa is showing 115% etco2 when ventilator settings is at 40% o2.No consequences or impact to patient were reported.

Manufacturer Narrative

Additional manufacturing narrative: other, other text: the returned device was evaluated.The module was left taking co2 measurements for 5 minutes using a 5% co2 gas mixture and measurement were within acceptable range.The module was left taking o2 measurements using a 51% o2 gas mixture and measurements always read 115% which means the measured value was out of range.A gas span calibration was attempted but was not successful as an error occurred.A known good o2 module was temporarily installed and the device is able to take o2 measurements.A service history record review reveals that this unit was in the field for over five (5) years with no previous reported issues related to this reported event.Initial reporter zip code exceeded the maximum allowable characters, zip code is as follows: (b)(6).

Event Description

The customer reported the isa is showing 115% etco2 when ventilator settings is at 40% o2.No consequences or impact to patient were reported.

• Brand Name: ISA OR+ KIT
• Type of Device: OXIMETER
• Manufacturer (Section D): MASIMO - 15750 ALTON PKWY; 15750 alton pkwy; irvine CA 92618
• Manufacturer (Section G): MASIMO - MEXICALI; industrial vallera de mexicali calzada del oro, no.2001; mexicali, baja california 21600 ; MX 21600
• Manufacturer Contact: matofa fautua ; 15750 alton pkwy; irvine, CA 92618 ; 9498223661
• MDR Report Key: 14059782
• MDR Text Key: 289108459
• Report Number: 3019388613-2022-00086
• Device Sequence Number: 1
• Product Code: CCK
• UDI-Device Identifier: 00843997009317
• UDI-Public: 00843997009317
• Combination Product (y/n): N
• Reporter Country Code: SN
• PMA/PMN Number: K063167
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,User Facility,Company Representative
• Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date: 03/15/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/08/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 37393
• Device Catalogue Number: 9685
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 05/09/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 12/02/2016
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1