|
Hamilton medical ag received the following event description: "event time arount 16:00 hours, 12/20 unit transporting patient from hospital, set patient up had no issues.Upon exiting hospital ventilator alarmed continuously.Crew was unable to silence the alarm, make setting changes, no buttons worked when pressed.Removed patient from ventilator and performed ventilations with bvm, secondary crew was dispatched to bring another ventilator.Unit in question was pulled from service.Note: ventilator shows in events tab tf codes: 785003, 446029,444004,485001.No health consequences or impact - no intervention necessary.
|
|
Investigation outcome: it was reported that the device alarmed for tf444004 voltage out of tolerance and switched into ambient during ventilation.On reviewing the device logs it was noticed that the failure occurred once only.The device started normally at next start-up.Review of the device logs confirmed a single occurrence of tf444004 (voltage out of tolerance) during ventilation, accompanied by additional technical faults (tf446029 and tf485001), resulting in transition to ambient mode.The event was transient and non-recurring, with the device subsequently starting and operating normally, indicating no persistent hardware failure.Detailed log analysis did not identify any alarms or fault codes associated with the p-filter, and therefore no direct evidence supports a p-filter-related root cause.While the local service engineer replaced the p-filter possibly as a precautionary measure, this action is not substantiated by log data.Following maintenance, including software update to version 3.1.1 and completion of service software, functional, and extended runtime testing, the device performed within specifications with no recurrence of the issue.No patient harm was reported, and manual ventilation was appropriately provided during the event.The complaint is concluded as a transient, non-reproducible power-related technical fault, with no confirmed link to p-filter performance, and the device was returned to service meeting all requirements.This case is considered as closed.
|