MAUDE Adverse Event Report: NELLCOR PURITAN BENNETT MEXICO SA NELLCOR; OXIMETER

Model Number	MAXI-NS
Medical Device Problem Code	Low Readings (2460)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/24/2025
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that the newborn patient's o2 saturation reading on the right wrist and right foot was reported to be 88-93%.Following the second pulse oxygen test, the o2 saturation on the right wrist and right foot was 88%-90%.An oxygen saturation reading of 98% was obtained on the right foot when another pulse oximeter was used.The pulse oximeter that was attached to the right wrist was removed, and the pulse oximeter from the right foot was moved to the right wrist and displayed o2 saturation of 98%.There was no patient injury.
Additional Manufacturer Narrative
D10 concomitant product: maxi-ns infant oxy sensor-non sterile (lot# 250900174h), medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide 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.Medtronic will submit a supplemental report if additional relevant information becomes known.
Additional Manufacturer Narrative
Additional information: b5, d4 (udi), g3.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide 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.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.
Event or Problem Description
It was reported that the newborn patient's o2 saturation reading on the right wrist and right foot was reported to be 88-93%.Following the second pulse oxygen test, the o2 saturation on the right wrist and right foot was 88%-90%.An oxygen saturation reading of 98% was obtained on the right foot when another pulse oximeter was used.The pulse oximeter that was attached to the right wrist was removed, and the pulse oximeter from the right foot was moved to the right wrist and displayed o2 saturation of 98%.The infant was in the radiant warmer under phototherapy but the phototherapy lights were turned off.The patient had a fair skin stone.There was no patient injury.
Additional Manufacturer Narrative
H3 evaluation summary: medtronic conducted an investigation based upon all information received.The device was available for evaluation.The evaluation found no potentially contributing factors, and the sample met all related specifications.It was reported that the newborn patient's o2 saturation reading on the right wrist and right foot was reported to be 88-93%.Following the second pulse oxygen test, the o2 saturation on the right wrist and right foot was 88%-90%.An oxygen saturation reading of 98% was obtained on the right foot when another pulse oximeter was used.The pulse oximeter that was attached to the right wrist was removed, and the pulse oximeter from the right foot was moved to the right wrist and displayed o2 saturation of 98%.The infant was in the radiant warmer under phototherapy but the phototherapy lights were turned off.The reported issue could not be confirmed.The most likely cause could not be identified because no related problem was detected with the device.The manufacturing records for each device are thoroughly reviewed prior to release to ensure that it meets all medtronic quality specifications.Medtronic submits this report to comply with fda regulations 21 cfr parts 4 and 803.Medtronic has made reasonable efforts to provide 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.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.Medtronic will submit a supplemental report if additional relevant information becomes known.

• Brand Name: NELLCOR
• Common Device Name: OXIMETER
• Manufacturer (Section D): NELLCOR PURITAN BENNETT MEXICO SA; boulevard insurgentes 19030; tijuana 22225 ; MX 22225
• Manufacturer (Section G): NELLCOR PURITAN BENNETT MEXICO SA; boulevard insurgentes 19030; tijuana 22225 ; MX 22225
• Manufacturer Contact: mike bocchino ; 8200 coral sea st ne; mounds view, MN 55112-4391 ; 8006464633
• MDR Report Key: 22461232
• Report Number: 9610849-2025-00001
• Device Sequence Number: 8058173
• Product Code: DQA
• UDI-Device Identifier: 20884522041284
• UDI-Public: (01)20884522041284(17)280229(10)250900174H
• Combination Product (Y/N): N
• Initial Reporter State: IA
• Initial Reporter Country: US
• PMA/510(K) Number: K012891
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Health Professional,Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 10/14/2025

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: MAXI-NS
• Device Catalogue Number: MAXI-NS
• Device Lot Number: 250900174H
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/27/2025
• Supplement Date Received by Manufacturer: 07/08/2025; 10/01/2025
• Initial Report FDA Received Date: 07/09/2025
• Supplement Report FDA Received Date: 07/25/2025; 10/15/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 03/31/2025
• 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: Unknown
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: SEE H11
• Patient Sex: Unknown