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A user facility¿s clinic manager (cm) reported that a visible internal dialyzer blood leak occurred immediately after the initiation of the patient¿s hemodialysis (hd) treatment.The machine, a fme 2008h machine, alarmed appropriately with a blood leak alarm.Blood leak test strips were not used because the leak was visible.A fme bloodline was in use.There was no obvious defect or damage seen on the dialyzer.The patient¿s estimated blood loss (ebl) was approximately 125ml.The patient was restarted on the same machine and treatment completed successfully with new supplies.There was no patient injury or medical intervention required due to the reported event.The complaint device is not available to be returned to the manufacturer for evaluation.One photo has been provided.
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Plant investigation: as the device was not returned to the manufacturer, a physical evaluation could not be performed.However, one photograph was provided by the customer.The photograph showed the dialyzer label from the reported lot number.No damage, defect, or leak was visible in the photograph.A specific cause of the leak was not visible in the photograph.A production records review was performed on the reported lot.An investigation of the device history records (dhr) was conducted by the manufacturer.There was one non-conformance (nc) in the production of this lot.It is unrelated to the reported complaint event.There was no indication of product nonacceptance, deviation, non-conformance, rework, labeling or process control failure during the manufacturing process which could be associated with the reported event.The lot met all release criteria.The investigation into the complaint was not able to confirm the reported event.Continuous improvement is of the utmost importance to fresenius medical care as we strive to provide dialysis products of the highest quality to our patients.Reports of leaking product are investigated both individually as complaints, as well as via the nc/capa program, in order to assess and improve our products and processes.Capas for vision systems and blood leak reduction are recent examples of leak related investigations directed at an overall reduction in dialyzer leaks.
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