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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: EDWARDS LIFESCIENCES DR TRUCLIP STAND, INFUSION

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EDWARDS LIFESCIENCES DR TRUCLIP STAND, INFUSION Back to Search Results
Model Number TCLIP05
Device Problems Incorrect, Inadequate or Imprecise Resultor Readings (1535); Detachment of Device or Device Component (2907)
Patient Problems Patient Problem/Medical Problem (2688); No Known Impact Or Consequence To Patient (2692)
Event Date 05/14/2018
Event Type  malfunction  
Manufacturer Narrative
The device was not returned for evaluation; it was discarded at the hospital. Without return of the unit it is not possible to determine if some damage or defect existed on the unit that could have contributed to the event. It is not known if some procedural factors may have contributed to the event. No corrective actions will be taken at this time. Lot number was not provided; therefore review of the manufacturing records could not be completed. The truclip is designed to keep the pressure transducer at the phlebostatic axis for accurate pressure readings. In the event that the truclip is broken and does not remain stationary on the iv pole, it is possible to receive inaccurate pressure values. Pressure readings should correlate with the patient¿s clinical manifestations. The truclip ifu includes a warning that states: ¿truclip must be mounted securely to ensure clinical stability and to prevent injury to the patient or user¿. The ifu also advises the clinician to clean the surface of the truclip before and after each use by wiping with 70% isopropyl alcohol or 5% bleach and inspect to ensure the integrity of the device. There is a caution in the ifu instructing the user not to sterilize the truclip. It is common clinical practice for the clinician to monitor the transducer vent port so that it corresponds to the chamber where the pressure is being measured. Clinicians routinely follow hospital policies and procedures for frequency of zeroing the transducer system and thereby monitoring the level of the truclip device. In this case the facility did not follow edwards instructions to not sterilize. 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 this monthly review. This is a 510k exempt as this is a class 1 device. Medwatch report number mw5081036.
 
Event Description
It was reported while measuring the patient¿s blood pressure, unknown to the nurse, the arterial blood pressure transducer had fallen off the clip and the blood pressure readings were falsely elevated and the medication was decreased based on the incorrect readings. After the event, inspection of the equipment found that the holders were warping due to the sterilization process. (sterilization is not recommended by manufacturer. ) patient demographics unable to be obtained. Follow up attempts have been made for the patient¿s condition. The device was discarded at the hospital.
 
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Brand NameTRUCLIP
Type of DeviceSTAND, INFUSION
Manufacturer (Section D)
EDWARDS LIFESCIENCES DR
parque industrial de itabo
carr. sanchez km 18.5
haina, san cristobal
DR
Manufacturer (Section G)
EDWARDS LIFESCIENCES DR
parque industrial de itabo
carr. sanchez km 18.5
haina, san cristobal
DR
Manufacturer Contact
lynn selawski
1 edwards way
irvine, CA 92614
9497564386
MDR Report Key8151775
MDR Text Key130659460
Report Number2015691-2018-05206
Device Sequence Number1
Product Code FOX
Combination Product (y/n)N
Reporter Country CodeUS
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
Report Date 11/19/2018
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received12/11/2018
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Model NumberTCLIP05
Was Device Available for Evaluation? No
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? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Reuse

Patient Treatment Data
Date Received: 12/11/2018 Patient Sequence Number: 1
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