MAUDE Adverse Event Report: COVIDIEN 840 VENTILATOR; VENTILATOR, CONTINUOUS, FACILITY USE

Model Number	4-840120DIJJ-JP
Medical Device Problem Code	No Flow (2991)
Health Effect - Clinical Codes	Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/23/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Patient identifier information cannot be provided due to the restriction by the japan privacy regulation.Section e: initial reporter information cannot be provided due to the restriction by the japan privacy regulation.Medtronic affiliate reported on behalf of the customer.H3 device evaluation summary: medtronic conducted an investigation based upon all information received.It was reported that while in use on a patient, this 840 v entilator generated a safety valve open message and a bad safety valve current diagnostic code.The device was available for evaluation.The service personnel (sp) inspected the ventilator and confirmed that the unit generated a relevant diagnostic code indicating that the device experienced a loss of ventilation at the time of the reported event.The sp replaced the safety valve and air-side pressure solenoids (psol).The ventilator passed all tests, calibrations.The likely cause of the event was isolated in the field to a potential fault in safety valve and/or psol valve.The manufacturing records for each device are thoroughly reviewed prior to release to ensure that it has met all medtronic quality s pecifications.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that while in use on a patient, this 840 ventilator generated a safety valve open message and a bad safety valve current diagnostic code.Although requested, patient status and intervention was unknown at this time.
Event or Problem Description
Updated: it was reported that while in use on a patient, this 840 ventilator generated a safety valve open message and a bad safety valve current diagnostic code.There was no reported patient injury.Although requested, patient intervention was unknown at this time.
Additional Manufacturer Narrative
Additional information: section b5 correction to h6 patient code and health impact code.Remove component code: g0201205.Correction: h3 device evaluation summary: medtronic conducted an investigation based upon all information received.It was reported that while in use on a patient, this 840 v entilator generated a safety valve open message and a bad safety valve current diagnostic code.The device was available for evaluation.The service personnel (sp) inspected the ventilator and confirmed that the unit generated a relevant diagnostic code indicating that the device experienced a loss of ventilation at the time of the reported event.The sp replaced the safety valve.Additionally, the sp replaced the air psol (proportional solenoid) valve as it was found the valve leak was high during the final check of the device.The device passed all the required tests and calibrations as per the manufacturer's specifications and was in working condition.The likely cause of the event was isolated to a potential fault in safety valve.The manufacturing records for each device are thoroughly reviewed prior to release to ensure that it has met all medtronic quality s pecifications.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Additional information: it was reported that while in use on a patient, this 840 ventilator generated a safety valve open message and a bad safety valve current diagnostic code.The patient was transferred to an alternate ventilator without injury.
Additional Manufacturer Narrative
Additional code added to section h6 evaluation code result correction to section h6 evaluation code conclusion and component.H3 device evaluation summary: updated due to part return.Medtronic conducted an investigation based upon all information received.Iit was reported that while in use on a patient, this 840 ventilator generated a safety valve open message and a bad safety valve current diagnostic code the device was available for evaluation.The service personnel (sp) inspected the ventilator and confirmed that the unit generated a relevant diagnostic code indicating that the device experienced a loss of ventilation at the time of the reported event.The sp replaced the safety valve.Additionally, the sp replaced the air psol (proportional solenoid) valve as it was found the valve leak was high during the final check of the device.The device passed all the required tests and calibrations as per the manufacturer's specifications and was in working condition.One safety valve was returned to medtronic for further analysis.The component was visually inspected and functionally tested with no malfunction or product deficiency observed.The replaced component did resolve the issue in the field however, the returned component safety valve was analyzed and tested satisfactorily.With the information available a likely cause could not be determined.The manufacturing records for each device are thoroughly reviewed prior to release to ensure that it has met all medtronic quality s pecifications.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: 840 VENTILATOR
• Common Device Name: VENTILATOR, CONTINUOUS, FACILITY USE
• Manufacturer (Section D): COVIDIEN; micheal collins rd mervue; galway ; EI
• Manufacturer (Section G): COVIDIEN; micheal collins rd mervue; galway ; EI
• Manufacturer Contact: justin ellis ; 8200 coral sea st ne; mounds view, MN 55112 ; 7635265677
• MDR Report Key: 15906511
• Report Number: 8020893-2022-00223
• Device Sequence Number: 5126511
• Product Code: CBK
• UDI-Device Identifier: 10884521076891
• UDI-Public: 10884521076891
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K970460
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 02/07/2023

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: 4-840120DIJJ-JP
• Device Catalogue Number: 4-840120DIJJ-JP
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/03/2022
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/10/2022
• Supplement Date Received by Manufacturer: 12/08/2022; 01/05/2023; 02/03/2023
• Initial Report FDA Received Date: 12/02/2022
• Supplement Report FDA Received Date: 12/27/2022; 01/09/2023; 02/08/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/19/2010
• 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: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown