MAUDE Adverse Event Report: MERGE HEALTHCARE MERGE HEMODYNAMICS; PROGRAMMABLE DIAGNOSTIC COMPUTER

Model Number MERGE HEMODYNAMICS 10.0.3

Device Problems Application Interface Becomes Non-Functional Or Program Exits Abnormally (1138); Failure to Transmit Record (1521); Device Issue (2379)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 11/08/2016

Event Type  malfunction  

Manufacturer Narrative

Merge technical support remotely accessed the customer's server and found an error message in the event viewer indicating that the video signal was lost.The customer was not aware of the proper sequence of rebooting the hemo monitor and client pc so that caused the hemo physio controls to be grayed out.Technical support assisted the customer in the proper reboot sequence.An internal investigation conducted by merge healthcare found that if the hemo monitor pc is powered up and there is no active network connection, the hemo monitor pc will report an appropriate error to the event log, but currently will not attempt any retries to establish the connection to the hemo client pc.No active network connection can occur if the cable between the hemo monitor pc and hemo client pc is disconnected, or if the hemo client pc has not been powered up.When communication fails, patient vitals continue to be displayed on the hemo monitor pc except for non-invasive blood pressure (nibp) data.This requires a reboot/restart of the hemo monitor pc which interrupts the ability to capture and document patient vitals.This problem has been addressed and will be corrected in a future version, merge hemo.

Event Description

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 connection to the hemo monitor was lost in the middle of a procedure.Upon rebooting the hemo system, the physio controls were grayed out on the hemo client pc.This resulted in ~45 minutes to 1 hour delay.During this time, the patient was moved to another lab and was monitored while troubleshooting efforts were performed.With merge hemo not presenting physiological data during treatment, there is a potential for delay of treatment that could result in harm to the patient.The customer reported that there was no harm to the patient and the procedure was completed successfully once the hemo monitor and client pc were rebooted using the proper sequence.(b)(4).

• Brand Name: MERGE HEMODYNAMICS
• Type of Device: PROGRAMMABLE DIAGNOSTIC COMPUTER
• Manufacturer (Section D): MERGE HEALTHCARE; 900 walnut ridge drive; hartland WI 53029
• Manufacturer (Section G): MERGE HEALTHCARE; 900 walnut ridge drive; hartland WI 53029
• Manufacturer Contact: michael diedrick ; 900 walnut ridge drive; harland, WI 53029 ; 2629123570
• MDR Report Key: 6157141
• MDR Text Key: 61900845
• Report Number: 2183926-2016-00813
• Device Sequence Number: 1
• Product Code: DQK
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K082421
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: user facility
• Reporter Occupation: Other
• Remedial Action: Notification
• Type of Report: Initial
• Report Date: 11/08/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/08/2016
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: MERGE HEMODYNAMICS 10.0.3
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 11/08/2016
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 05/06/2016
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Removal/Correction Number: 2183926-02/15/2016-041-C
• Patient Sequence Number: 1