Model Number MERGE HEMODYNAMICS 10.0.1 |
Device Problems
Application Interface Becomes Non-Functional Or Program Exits Abnormally (1138); Failure to Transmit Record (1521); Device Issue (2379)
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Patient Problem
No Known Impact Or Consequence To Patient (2692)
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Event Date 01/18/2016 |
Event Type
malfunction
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Manufacturer Narrative
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The customer's reported problem is currently under investigation by merge healthcare.For this reason, conclusions code (conclusion not yet available-evaluation in progress) was used.When more information becomes available, a supplemental report will be submitted.
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Event Description
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Merge hemodynamics monitors, measures, and records physiological data from a human patient undergoing a cardiac catheterization procedure.The system comprises the patient data module and the merge hemodynamics hemo monitor pc.The two units are connected via a serial interface.All vital parameters and evaluations are registered and calculated in the patient data module.This data is then transmitted to the merge hemodynamics hemo monitor pc via the serial interface.All data can be shown and monitored on the merge hemodynamics hemo monitor pc.On (b)(6) 2016, a customer reported to merge healthcare that the hemo monitor "went black on all three of the hemo displays" during a case.It was further reported that the problem resulted in a delay in treatment; however, the customer reported that "there was no negative patient outcome as a result of this failure." during internal trending analysis activities conducted (b)(6) 2016, it was found that this complaint meets the criteria as a reportable event to the fda because there was a potential for patient harm.With merge hemo not presenting physiological data during treatment, there is a potential for a delay in care that results in harm to the patient.However, the customer reported that the procedure was completed successfully once the hemo monitor was rebooted.Reference complaint number (b)(4).
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Manufacturer Narrative
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Merge healthcare conducted an internal quality investigation to address the issue reported in recall 2183926-02/15/2016-031-c, fda recall number z-0665-2017.Merge healthcare received reports of the hemo monitor application unexpectedly stopping to display and update patient data.When this issue occurs, the hemodynamics system is no longer capturing patient data.For customers who experience this issue, it is recommended that the hemo monitor pc is power cycled.Once the system is powered up, the hemo application should restart with normal functionality and will once again display, update and record patient data.The restarting of the hemo monitor pc may result 0630in a delay of up to two minutes while the system reboots.The investigation and troubleshooting activities conducted by merge healthcare found that the issue occurred due to an error when interfacing with a specific location within a schiller pdm (patient data module) file.Merge has validated and released a firmware fix for this issue.This fix is incorporated into the software upgrade of merge hemo 9.40.3 patch 1 (or later), or merge hemo 10.0.3 patch 1 (or later).The correction has been verified to be effective as is evidenced through the large reduction of customer complaints concerning this issue.Revised information contained in this supplemental report includes the following: updated contact office - name/address.Date new information received by manufacturer (planned implementation date).Indication that this is follow-up report 1.Indication of malfunction as reportable event.Indication of additional information and device evaluation.Indication that device evaluated by manufacturer.Evaluation codes: methods: 22 software evaluation: results: 110 design error [the device or component had faulty (incomplete or incorrect) software design].Conclusions code: 12 design deficiency [the device problem was traced back to the design specifications (e.G.In the requirements, testing processes, hazard analysis, implementation strategy].Addition of fda assigned recall reporting number.Indication of additional manufacturer information is contained in this follow-up report.
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Search Alerts/Recalls
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