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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: OGDEN MANUFACTURING PLANT OPTIFLUX 180NRE DIALYZER FINISHED ASSY.; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM

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OGDEN MANUFACTURING PLANT OPTIFLUX 180NRE DIALYZER FINISHED ASSY.; DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM Back to Search Results
Model Number 0500318E
Device Problem Fluid/Blood Leak (1250)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 10/12/2022
Event Type  malfunction  
Event Description
A user facility registered nurse (rn) reported that a blood leak occurred during on (b)(6) 2022 immediately after the start of the patient¿s hemodialysis (hd) treatment.The rn confirmed that the machine, a fresenius 2008t machine, alarmed appropriately with a "minor" blood leak alarm.Blood leak test strips were not used as blood was visually observed within the dialyzer housing and along the arterial line.The rn also stated that fresenius bloodlines were used for treatment and confirmed that the leak was internal and no external blood leak was observed.The rn stated that there were no defects or damage seen on the dialyzer.Per rn the patient¿s blood was not returned and stated the estimated blood loss was 10cc.Immediately following the event, the patient was re-setup with new supplies on a different machine where the patient was able to complete treatment.The rn confirmed that there was no patient injury, adverse events, or medical intervention required as a result of the reported event.The dialyzer was available to be returned for manufacturer evaluation.
 
Manufacturer Narrative
The plant investigation is in process.A supplemental mdr will be submitted upon completion of this activity.
 
Manufacturer Narrative
Plant investigation: the reported complaint was not confirmed as the complaint device was not returned to date for manufacturer evaluation.A production records review was performed on the reported lot.An investigation of the device history records (dhr) was conducted by the manufacturer.There was no indication of product nonacceptance, deviation, non-conformance, rework, labeling or process control failure during the manufacturing process which could be associated with the reported event.During the lot history review it was noted that there were two other complaints reported against the lot.One complaint is not associated with the current event.The other complaint addresses an internal blood leak (no sample).A definitive conclusion regarding the complaint incident cannot be reached without physical examination of the actual device.Therefore, the complaint is not confirmed.The reported lot number passed pyrogen testing, was within sterilization dosage parameters and passed all release criteria.Continuous improvement is of the utmost importance to fresenius medical care as we strive to provide dialysis products of the highest quality to our patients.Reports of leaking product are investigated both individually as complaints, as well as via the nc/capa program, in order to assess and improve our products and processes.Capas 2018-0171 (vision systems) and 2018-0161 (blood leak reduction) are recent examples of leak related investigations directed at an overall reduction in dialyzer leaks.
 
Event Description
A user facility registered nurse (rn) reported that a blood leak occurred during on (b)(6)2022 immediately after the start of the patient¿s hemodialysis (hd) treatment.The rn confirmed that the machine, a fresenius 2008t machine, alarmed appropriately with a "minor" blood leak alarm.Blood leak test strips were not used as blood was visually observed within the dialyzer housing and along the arterial line.The rn also stated that fresenius bloodlines were used for treatment and confirmed that the leak was internal and no external blood leak was observed.The rn stated that there were no defects or damage seen on the dialyzer.Per rn the patient¿s blood was not returned and stated the estimated blood loss was 10cc.Immediately following the event, the patient was re-setup with new supplies on a different machine where the patient was able to complete treatment.The rn confirmed that there was no patient injury, adverse events, or medical intervention required as a result of the reported event.The dialyzer was available to be returned for manufacturer evaluation.
 
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Brand Name
OPTIFLUX 180NRE DIALYZER FINISHED ASSY.
Type of Device
DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
Manufacturer (Section D)
OGDEN MANUFACTURING PLANT
director, site quality
475 west 13th street
ogden UT 84404
Manufacturer (Section G)
OGDEN MANUFACTURING PLANT
director, site quality
475 west 13th street
ogden UT 84404
Manufacturer Contact
jessica trujillo
920 winter st
waltham, MA 02451
6174175172
MDR Report Key15624228
MDR Text Key306693298
Report Number0001713747-2022-00425
Device Sequence Number1
Product Code KDI
UDI-Device Identifier00840861100156
UDI-Public00840861100156
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
K162488
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Health Professional,User Facility,Company Representative
Reporter Occupation Nurse
Type of Report Initial,Followup
Report Date 11/23/2022
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received10/18/2022
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Health Professional
Device Model Number0500318E
Device Catalogue Number0500318E
Device Lot Number22EU05001
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? Yes
Device AgeMO
Date Manufacturer Received11/23/2022
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured05/15/2022
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial
Patient Sequence Number1
Treatment
FRESENIUS 2008T MACHINE; FRESENIUS 2008T MACHINE; FRESENIUS BLOODLINES; FRESENIUS BLOODLINES
Patient Age79 YR
Patient SexMale
Patient Weight102 KG
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