MAUDE Adverse Event Report: RESPIRONICS, INC. EVERFLO OXYGEN CONCENTRATOR; GENERATOR, OXYGEN, PORTABLE

Model Number	1039362
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Burn(s) (1757)
Date of Event	11/16/2017
Type of Reportable Event	Serious Injury
Event or Problem Description
The manufacturer received a voluntary medwatch, mw5073861, alleging a nasal cannula being used with an everflo oxygen concentrator caught fire while the patient was cooking on an electric stove.The patient received burns to her face and was admitted to the hospital 3 days later.The device is not returning to the manufacturer for evaluation.The durable medical equipment (dme) supplier stated there was no evidence of damage to the device.The dme tested the device and the device passed all testing and was placed back in the field.Product labeling states,"oxygen vigorously accelerates combustion and should be kept away from heat or open flame.Not suitable for use in the presence of a flammable anesthetic mixture with air or with oxygen or nitrous oxide.Do not smoke, allow others to smoke or have open flames near the concentrator when it is in use.".
Additional Manufacturer Narrative
The manufacturer previously reported the date of the event and date of the report as (b)(6) 2018.The correct date of the event and date of the report is (b)(6) 2018.

• Brand Name: EVERFLO OXYGEN CONCENTRATOR
• Common Device Name: GENERATOR, OXYGEN, PORTABLE
• Manufacturer (Section D): RESPIRONICS, INC.; 175 chastian meadows court; kennesaw GA 30144 3724
• MDR Report Key: 7168575
• Report Number: 1040777-2018-00001
• Device Sequence Number: 1455606
• Product Code: CAW
• UDI-Device Identifier: 00606959032668
• UDI-Public: 00606959032668
• Combination Product (Y/N): N
• Initial Reporter State: NY
• Initial Reporter Country: US
• PMA/510(K) Number: K061261
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Medical Equipment Company Technician/Representative
• Type of Report: Initial,Followup
• Report Date (Section B): 01/03/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Lay User/Patient
• Device Model Number: 1039362
• Device Catalogue Number: 1039362
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 01/03/2018
• Supplement Date Received by Manufacturer: 01/11/2018
• Initial Report FDA Received Date: 01/05/2018
• Supplement Report FDA Received Date: 01/11/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization
• Patient Age: 62 YR