MAUDE Adverse Event Report: MASIMO - 40 PARKER RD SET TC-I; OXIMETER

Model Number	4053-9
Medical Device Problem Code	Low Readings (2460)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/25/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device has been returned to the local facility but has not yet been received at the main office for evaluation.Once the device has been returned and investigated, a follow-up report will be submitted.
Event or Problem Description
The customer reported the sensor is providing inaccurately low readings.No patient impact or consequences were reported.
Additional Manufacturer Narrative
Additional manufacuring narrative: the returned sensor was evaluated.Visual inspection upon receiving revealed no external damage.Passed continuity tests, no short or open connection was detected, and no intermittent short or open connection was detected when sensor was manipulated.The sensor passed spo2 and pulse rate comparison tests against lab sensor.The sensor is functioning as designed., corrected data: corrected data: model # was corrected from 4053 to 4053-9.
Event or Problem Description
The customer reported the sensor is providing inaccurately low readings.No patient impact or consequences were reported.

• Brand Name: RD SET TC-I
• Common Device Name: OXIMETER
• Manufacturer (Section D): MASIMO - 40 PARKER; 40 parker; irvine CA 92618 1604
• MDR Report Key: 8187911
• Report Number: 2031172-2018-00581
• Device Sequence Number: 1987180
• Product Code: DPZ
• UDI-Device Identifier: 00843997009904
• UDI-Public: 00843997009904
• Combination Product (Y/N): N
• Initial Reporter Country: SW
• PMA/510(K) Number: K051212
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Biomedical Engineer
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 11/25/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 4053-9
• Device Catalogue Number: 4053
• Device Lot Number: 18E04
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/03/2018
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 11/25/2018
• Supplement Date Received by Manufacturer: 01/14/2019
• Initial Report FDA Received Date: 12/20/2018
• Supplement Report FDA Received Date: 02/05/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1