| Catalog Number |
10310 |
| Medical Device Problem Codes |
Use of Device Problem (1670); Insufficient Device Problem Information (3190); Device Handling Problem (3265)
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| Health Effect - Clinical Code |
Numbness (2415)
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| Date of Event |
03/30/2026
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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Lot number, manufacture date and expiry date are not available at this time.Investigation: per the customer, this occurred because the port of the saline bag was orange in color, which led to the orange ac spike being connected, and because the experienced operator did not perform a double check. the hospital¿s response was to use saline bags with ports that are not orange in color and to ensure that double checks are always performed.Investigation is in process, a follow-up report will be provided.
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Event or Problem Description
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The customer reported that the ac spike and the saline spike were mistakenly interchanged during a procedure on spectra optia.The issue was noticed during the procedure and the processing was terminated.The patient experienced numbness due to hypocalcemia at an early stage after the start of collection.The ionized calcium level measured at that time was 1.2 mmol.When the customer contact a tbct representative, he advised that rinseback should not be performed; however, by that time, the saline had already been reconnected to the inlet side manifold and rinseback had been performed.Per the customer, "the symptoms subsequently improved" patient information is unknown at this time.The collection set is not available for return because it was discarded by the customer.
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Search Alerts/Recalls
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