MAUDE Adverse Event Report: MASIMO - 15750 ALTON PKWY KIT, EMMA CAPNOGRAPH, MMHG; OXIMETER

Model Number	27803
Medical Device Problem Code	High Readings (2459)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/26/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device has not been returned to the investigation facility to allow for an analysis to be performed.If the product is received for evaluation or new information is obtained, a follow up report will be submitted.
Event or Problem Description
The customer reported the etco2 value was unstable, the value seems to be abnormally high.No patient impact or consequences were reported.
Event or Problem Description
The customer reported the etco2 value was unstable, the value seems to be abnormally high.No patient impact or consequences were reported.
Additional Manufacturer Narrative
Additional manufacturing narrative: other, other text: the returned device was evaluated.Visual inspection found the detector lens was recessed.The device was able to power on and off using battery power and was able to obtain measurements with all of the enabled parameters.When a co2 gas mixture was applied, the device measured outside the accuracy specification.After performing zeroing of the device, the measured value remained outside of the accuracy specification due to the recessed detector lens.

• Brand Name: KIT, EMMA CAPNOGRAPH, MMHG
• Common Device Name: 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: 15889982
• Report Number: 3019388613-2022-00252
• Device Sequence Number: 6699708
• Product Code: CCK
• UDI-Device Identifier: 07350046131033
• UDI-Public: 07350046131033
• Combination Product (Y/N): N
• Initial Reporter Country: KS
• PMA/510(K) Number: K072813
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Company Representative,Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/31/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 27803
• Device Catalogue Number: 3639
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/31/2022
• Supplement Date Received by Manufacturer: 12/05/2022
• Initial Report FDA Received Date: 11/30/2022
• Supplement Report FDA Received Date: 12/22/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/04/2020
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown