MAUDE Adverse Event Report: MASIMO - 40 PARKER RD SET MP - 12; OXIMETER

Model Number	4083
Medical Device Problem Code	Incorrect Measurement (1383)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/13/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional manufacturing narrative: attempts have been made to obtain the product.The product has not been returned to masimo to allow an analysis to be performed.If the product is returned for evaluation or new information is obtained, a follow up report will be submitted.(b)(6).
Event or Problem Description
The customer reported seeing an spo2 of 39% on the patient which did not match the clinical picture when using a philips mp 50 with fast via a mms module.Replacing the cable resolved the issue.These failures occurred in six beds in a small long term pediatric ventilator unit.No consequences or impact to patient were reported.
Additional Manufacturer Narrative
The returned cable was evaluated and found to be functioning as designed.No product performance issue identified, based on the investigation above, the customer complaint could not be duplicated.

• Brand Name: RD SET MP - 12
• Common Device Name: OXIMETER
• Manufacturer (Section D): MASIMO - 40 PARKER; 40 parker; irvine CA 92618 1604
• MDR Report Key: 6075997
• Report Number: 2031172-2016-01209
• Device Sequence Number: 2102250
• Product Code: DQA
• UDI-Device Identifier: 00843997009782
• UDI-Public: (01)00843997009782(11)160901(10)16J2C
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K042536
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Other
• Remedial Action: Other
• Type of Report: Initial,Followup,Followup

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 4083
• Device Catalogue Number: 4083
• Device Lot Number: 16J2C
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/29/2016
• Was the Report Sent to FDA?: Yes
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 10/13/2016
• Supplement Date Received by Manufacturer: Not provided; Not provided
• Initial Report FDA Received Date: 11/03/2016
• Supplement Report FDA Received Date: 12/21/2016; 01/17/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1