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Model Number 194371001
Device Problem Fire (1245)
Patient Problems No Consequences Or Impact To Patient (2199); No Known Impact Or Consequence To Patient (2692)
Event Date 10/30/2018
Event Type  malfunction  
Manufacturer Narrative
The product is expected to be returned for analysis; however, it has not been received yet. Upon the return of the product a supplemental report will be sent with the investigation results. The design history review is pending and the results will be submitted by a supplemental report.
Event Description
It was reported that there was a fire at the connection site of the clearsight pump unit and the power cord. This occurred during patient monitoring in the sicu. An investigation by the edwards field clinical specialist found that a saline bag was hanging over the components on the equipment pole at the time of the occurrence. There was no harm or injury to the patient or to hospital personnel. The hospital personnel have been provided information as to the proper placement of the equipment and to keep away from liquid. They have been provided clips to hang the equipment properly by the edwards cfs. The patient demographic information has not been provided. Refer to 2015691-2018-04841 for the pump unit mdr submission.
Manufacturer Narrative
One clearsight power cord was returned for product evaluation. The devices were examined and analyzed and it was identified that the source of the issue originated at the ac plug area entering into the pump unit. There is a burned area and a white crystalline material noted on the back and both sides of the unit. Higher magnification of the white residue suggests a white material with a crystalline structure. The eds indicates that the white residue consists of sodium and chlorine. This suggests the matrix is sodium chloride, a saline solution. The optical and sem/eds analysis of the devices suggests the issue was caused by a saline solution dripping and saturating the ac power plug that enters into the unit. The clearsight ifu in chapter 2 includes a warning that instructs the user, ¿do not allow any liquid to come in contact with the power connector. [or] allow any liquid to penetrate connectors or the openings in the case. ¿ the edwards clinical field representative performed an in service visit to the facility and educated the hospital personnel on the proper way to hang the equipment on the equipment pole. She provided clips for the equipment. She advised ¿not to hang the saline bags above the equipment¿. This is not a systemic or design related issue. There is no indication that a manufacturing defect contributed to the failure. The device service history record review could not be completed as the serial/lot number is unknown. The udi is (b)(4). Refer to the pump unit submission 20155691-2018-04841. The reported event was confirmed by evaluation. The root cause is consistent with liquid ingress and customer mishandling. There will be no further actions taken at this time. 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 a part of the monthly review. Additional information obtained from the hospital states that the patient was an unresponsive male patient in the sicu that was being monitored with a non-invasive a-line. When the incident occurred, the patient was evacuated from the room. There was no harm or injury to the patient.
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Brand NamePOWER CORD, 110V
Type of DevicePOWER CORD
Manufacturer (Section D)
one edwards way
irvine CA 92614
Manufacturer (Section G)
one edwards way
irvine CA 92614
Manufacturer Contact
lynn selawski
one edwards way
irvine, CA 92614
MDR Report Key8094801
MDR Text Key128582520
Report Number2015691-2018-04842
Device Sequence Number1
Product Code DXN
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative,health
Reporter Occupation Other Health Care Professional
Type of Report Initial,Followup,Followup
Report Date 10/30/2018
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received11/21/2018
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Model Number194371001
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer11/30/2018
Is the Reporter a Health Professional? Yes
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received07/23/2020
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Is the Device Single Use? No
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Reuse