MAUDE Adverse Event Report: AVANOS MEDICAL INC. AMBIT ELECTRONIC PAIN CONTROL PUMP; ELECTRONIC INFUSION PUMPS & SYSTEMS

Model Number	220527
Medical Device Problem Code	Excess Flow or Over-Infusion (1311)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/13/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The returned product was evaluated and no issues were observed on device.The root cause could not be determined since the reported failure was not reproduced in lab during sample evaluation.The summit pump is manufactured by providien and the serial number that was provided could not be traced back to a lot number; therefore, a dhr was not opened, and no analysis of production records could be performed.All information reasonably known as of 27 apr 2023 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical inc.Avanos medical inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an avanos medical inc.Product is defective or caused serious injury.
Event or Problem Description
Fill volume: unknown.Flow rate: 8ml/4ml.Procedure: total knee replacement.Cathplace: unknown.Infusion start time: (b)(6) 2023 at 1349.Infusion stop time: (b)(6) 2023 at 1620.It was reported, the pump was started at 1349 and by 1620 had delivered 112ml of anesthetic to the patient; during placement, the nurse confirmed the rx pump settings were correct, (8ml an hour with a 4ml bolus time of 30 min).When the nurse checked on the patient they noted the pump was running continuously; the pump was removed and replaced, (but paused until the following day)- the patient was to stay overnight for observation.There was no reported injury to the patient.Additional information received 20feb2023 reported, the patient was a planned same day surgery; however, was kept due to pump and risk of toxicity.There were no signs of local anesthetic toxicity (lsat), the patient was placed on tele and monitored.

• Brand Name: AMBIT ELECTRONIC PAIN CONTROL PUMP
• Common Device Name: ELECTRONIC INFUSION PUMPS & SYSTEMS
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• Manufacturer (Section G): SUMMIT MEDICAL PRODUCTS, INC.; 504 west 8360 south; sandy UT 84070
• Manufacturer Contact: lisa clark ; 5405 windward parkway; alpharetta, GA 30004 ; 4704485444
• MDR Report Key: 16831958
• Report Number: 3011270181-2023-00033
• Device Sequence Number: 7131894
• Product Code: FRN
• UDI-Device Identifier: 00193494000769
• UDI-Public: 00193494000769
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K162165
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/28/2023

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: 220527
• Device Lot Number: 345861
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/06/2023
• 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: 04/09/2023
• Initial Report FDA Received Date: 04/28/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: BUPIVICAINE 0.125%
• Patient Sex: Female
• Patient Weight: 86 KG