MAUDE Adverse Event Report: MASIMO - 15750 ALTON PKWY RD SET NEOPT CS-3; OXIMETER

Model Number	4479
Medical Device Problem Code	Incorrect Measurement (1383)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/01/2023
Type of Reportable Event	Malfunction
Event or Problem Description
The customer reported inaccurate values.No consequences or impact to patient were reported.
Additional Manufacturer Narrative
Additional manufacturing 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.Initial reporter phone number: (b)(6).
Additional Manufacturer Narrative
Additional manufacuring narrative: other, other text: the returned sensor was evaluated.During evaluation, no product performance issues related to the accuracy of spo2 and pulse values.Initial reporter phone number exceeded maximum allowable digits, phone number is as follows: (b)(6), corrected data: g4.Date received by manufacturer was submitted as 07-mar-2023, actual is 09-mar-2023.
Event or Problem Description
The customer reported inaccurate values.No patient impact or consequences were reported.

• Brand Name: RD SET NEOPT CS-3
• 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: tahereh sedighi ; 15750 alton pkwy; irvine, CA 92618 ; 9492977862
• MDR Report Key: 16665545
• Report Number: 3019388613-2023-00103
• Device Sequence Number: 5973151
• Product Code: DQA
• UDI-Device Identifier: 10843997013311
• UDI-Public: 10843997013311
• Combination Product (Y/N): N
• Initial Reporter Country: BE
• PMA/510(K) Number: K101896
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Pharmacist
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/09/2023

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 Expiration Date: 07/01/2025
• Device Model Number: 4479
• Device Catalogue Number: 4479
• Device Lot Number: 22GBR
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/07/2023
• Supplement Date Received by Manufacturer: 04/17/2023
• Initial Report FDA Received Date: 04/03/2023
• Supplement Report FDA Received Date: 05/10/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 07/07/2022
• 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 Age: 1 MO
• Patient Sex: Male
• Patient Weight: 2 KG