MAUDE Adverse Event Report: INFU TRONIX, LLC NIMBUS II PLUS AMBULATORY INFUSION PUMP

Model Number	NIMBUS LL PLUS
Medical Device Problem Codes	Mechanical Problem (1384); Infusion or Flow Problem (2964)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/21/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A review of the device history record has been completed.The pump passed all previous tests.Complaint data was reviewed , there is a previous complaint : (b)(4)., on the device.Device return requested.This mdr will be reopened and updated in the event the device involved or additional information becomes available.
Event or Problem Description
Patient had pump alarming system error.
Event or Problem Description
On 06-jun-2024, infutronix received the pump which was previously requested to be returned for investigation.
Additional Manufacturer Narrative
This follow-up 1 report includes: correction to section: d.4 (catalog), and new or additional information to sections: b.4, b.5, d.9, g.3, g.6, h.2, h.3, h.6, h.7, h.9, h.10, and h.11.On (b)(6) 2024, this pump underwent visual, physical, and functional testing per internal protocol by the complaint evaluation specialist to investigate the reported alarming system error.The visual/physical analysis did not find any anomalies and verified the pump's library was configured properly.Review of the device error log confirmed the reported system error alarm (e02) and followed by a sub-code, motor delay issue (44).Review of the pump's records found testing passed successfully.The functional testing using simulated customer parameters for a 24-hour infusion completed successfully.Although the functional analysis was unable to duplicate the reported system error alarm, the noted sub-code (44) suggests the root cause is associated to the pump's motor.A capa was established to investigate this failure mode to determine root cause.Note: this pump is included in recall # z-1285-2024 as noted in sections d.7, d.9, and therefore further individual investigation was not deemed required.

• Brand Name: NIMBUS II PLUS AMBULATORY INFUSION PUMP
• Common Device Name: AMBULATORY INFUSION PUMP
• Manufacturer (Section D): INFU TRONIX, LLC; 177 pine street; natick MA 01760
• Manufacturer (Section G): INFU TRONIX, LLC; 177 pine street; natick MA 01760
• Manufacturer Contact: frederick lee ; 177 pine street; natick, MA 01760
• MDR Report Key: 18965143
• Report Number: 3011581906-2024-00309
• Device Sequence Number: 12525319
• Product Code: FRN
• UDI-Device Identifier: 00817170020093
• UDI-Public: 00817170020093
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K153193
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative,Distributor
• Initial Reporter Occupation: Other
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 07/04/2024

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: Lay User/Patient
• Device Model Number: NIMBUS LL PLUS
• Device Catalogue Number: NIMBUS G
• Device Lot Number: 170829-240
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/22/2024
• Supplement Date Received by Manufacturer: 06/06/2024
• Initial Report FDA Received Date: 03/22/2024
• Supplement Report FDA Received Date: 07/04/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-1285-2024
• Patient Sequence Number: 1
• Patient Age: 62 YR
• Patient Sex: Unknown