| Catalog Number |
60000000L |
| Medical Device Problem Code |
Device Sensing Problem (2917)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
11/25/2025
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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The investigation is still in progress.Once the investigation is complete a supplemental report will be filed.Udi format updated with available product information per gudid.H11: section a through f - the information provided by bd represents all 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 bd.
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Event or Problem Description
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It was reported that the nurse stated they started cooling a patient about an hour and a half ago.The targeted temperature (tt) was 36c.The patient cooled below the target and was currently 34.9c.S/n (b)(6).Confirmed water temperature was 38.5c and water flow rate (wfr) was 3.4 l/min.Nurse stated they had medium pads on the patient with good skin coverage.Explained the device was making extremely warm water and appears to be responding appropriately.Patient was fully sedated and was not shivering, no signs of heat generation.Nurse stated when they initiated therapy, the patient was not fully sedated.Explained the device may have recognized heat generation if the patient was moving or shivering which can lead to overshoot.Water temperature was up to 40c.Suggested nurse consult their protocol for counter warming such as warm blankets, bair hugger, vent warmer etc.To help increase the patient's temperature.Also discussed with prolonged warm water exposure, they may increase their skin checks frequency.Encouraged nurse to call back with any questions or issues.
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Event or Problem Description
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It was reported that the nurse stated they started cooling a patient about an hour and a half ago.The targeted temperature (tt) was 36c.The patient cooled below the target and was currently 34.9c.S/n (b)(6).Confirmed water temperature was 38.5c and water flow rate (wfr) was 3.4 l/min.Nurse stated they had medium pads on the patient with good skin coverage.Explained the device was making extremely warm water and appears to be responding appropriately.Patient was fully sedated and was not shivering, no signs of heat generation.Nurse stated when they initiated therapy, the patient was not fully sedated.Explained the device may have recognized heat generation if the patient was moving or shivering which can lead to overshoot.Water temperature was up to 40c.Suggested nurse consult their protocol for counter warming such as warm blankets, bair hugger, vent warmer etc.To help increase the patient's temperature.Also discussed with prolonged warm water exposure, they may increase their skin checks frequency.Encouraged nurse to call back with any questions or issues.
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Additional Manufacturer Narrative
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The reported issue was inconclusive.The root cause for the reported event could not be determined.Confirmed water temperature was 38.5c and water flow rate (wfr) was 3.4 l/min.Nurse stated they had medium pads on the patient with good skin coverage.Explained the device was making extremely warm water and appears to be responding appropriately.Patient was fully sedated and was not shivering, no signs of heat generation.Nurse stated when they initiated therapy, the patient was not fully sedated.Explained the device may have recognized heat generation if the patient was moving or shivering which can lead to overshoot.Water temperature was up to 40c.Suggested nurse consult their protocol for counter warming such as warm blankets, bair hugger, vent warmer etc.To help increase the patient's temperature.Also discussed with prolonged warm water exposure, they may increase their skin checks frequency.Encouraged nurse to call back with any questions or issues.The complaint or reported issue was confirmed through other elements of the investigation to not be manufacturing related.The instructions-for-use are found to be adequate.The ifu currently instructs the user on the proper method to use this device to avoid undue injury to the patient and damage to the product.Based on the results of the investigation, no additional actions are needed.Correction: d.Udi format updated with available product information per gudid.H11: sections a through f - the information provided by bd represents all 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 bd.
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Search Alerts/Recalls
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