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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: EDWARDS LIFESCIENCES CLEARSIGHT EVHRS NON-INVASIVE HEART REFERENCE SENSOR

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EDWARDS LIFESCIENCES CLEARSIGHT EVHRS NON-INVASIVE HEART REFERENCE SENSOR Back to Search Results
Model Number EVHRS
Device Problems Incorrect Measurement (1383); Incorrect, Inadequate or Imprecise Resultor Readings (1535); Device Slipped (1584)
Patient Problems No Consequences Or Impact To Patient (2199); No Known Impact Or Consequence To Patient (2692)
Event Date 09/10/2018
Event Type  Injury  
Manufacturer Narrative
The device has been received for examination and the evaluation is in progress. When the evaluation findings are available a supplemental report will be submitted. The device service history record review has not been completed. When the results are available a supplemental report will be submitted. (b)(4).
 
Event Description
It was reported that during patient monitoring with clearsight technology that the heart reference sensor (hrs) device provided inaccurate blood pressure readings. This was because the hrs device fell off of the patient¿s gown and dropped to the floor. It had been secured by a clip to the gown, but came loose and fell off. The appropriate position of the hrs was to be at the patient¿s heart level. The patient was on anti-hypertensive treatment. At some point during titration of medication is when the hrs device fell off. This led to a period of time where the sbp, dbp and map was about 40mmg higher than the actual blood pressure reading. When the edwards clinical field specialist returned to the er she realized that the hrs was positioned incorrectly. At the time the blood pressure reading was 160/100. When the hrs was placed at heart level the blood pressure reading was 110/70. Non-invasive blood pressure monitoring was being used with the clearsight monitoring during surgery. This was a hypertensive crisis patient with blood pressure of 240/140s in the er. There was no harm or injury to the patient. This event was not a result of a product malfunction.
 
Manufacturer Narrative
One heart reference sensor (hrs) was returned for product evaluation. The suspect hrs device was connected to a known good working clearsight system for analysis and testing. The hrs device was able to be zeroed appropriately and there were no error messages noted. A normal waveform and normal blood pressure readings were able to be obtained without any issues. The device passed the ft2 functional testing. A visual external inspection was performed and there was no physical damage identified. There was no defect found. With any hemodynamic monitoring, pressure readings can change quickly and dramatically. Pressure readings should correlate with the patient¿s clinical manifestations. Clinicians are trained to evaluate the entire clinical presentation of the patient in order to make such decisions. In addition, these devices are used by highly trained clinicians experienced in assessing and mitigating any hazards that arise. There was no patient injury or compromise in this event. The patient demographic information was not provided. Complaint histories for all reported events are reviewed against trending control limits on a monthly basis and any excursions above the control limits are assessed and documented as part of the monthly review. The product evaluation did not confirm any defect with the hrs device. The root cause of the issue is consistent with user error. There is no evidence or indication that a manufacturing defect is a contributing factor; therefore, no corrective action was taken. The facility was provided education and training by an edwards clinical field specialist/nurse practitioner as to the proper use of the hrs device. The issue will continue to be monitored and trended as part of the management review process. No further action will be taken at this time.
 
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Brand NameCLEARSIGHT EVHRS
Type of DeviceNON-INVASIVE HEART REFERENCE SENSOR
Manufacturer (Section D)
EDWARDS LIFESCIENCES
one edwards way
irvine CA 92614
MDR Report Key7928257
MDR Text Key122453023
Report Number2015691-2018-04000
Device Sequence Number1
Product Code DXN
Combination Product (y/n)N
PMA/PMN Number
K140312
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,health
Type of Report Initial,Followup,Followup
Report Date 09/11/2018
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received10/02/2018
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator
Device Expiration Date09/06/2018
Device Model NumberEVHRS
Device Catalogue NumberEVHRS
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer09/25/2018
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received07/23/2020
Is This a Reprocessed and Reused Single-Use Device? No

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