Catalog Number 10-110 |
Device Problems
Break (1069); Crack (1135); Leak/Splash (1354)
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Patient Problems
Cerebrospinal Fluid Leakage (1772); No Consequences Or Impact To Patient (2199)
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Event Date 12/10/2018 |
Event Type
Injury
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Manufacturer Narrative
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The device is not available for returned to the manufacturer for analysis.The plant investigation is in progress and a supplemental medwatch report will be submitted upon completion of the investigation.Linked to mfr.Report number: 2648988-2019-00013, 2648988-2019-00015, 2648988-2019-00016, 2648988-2019-00017.
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Event Description
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This is 2 of 5 reports.A risk management specialist that a 10110 csf drainage system was cracked.Additional information was received on 01-feb-2019 indicating that the external ventricular drain (evd) set up was reinstated.On (b)(6) 2018, a break in the evd tubing occurred at the neck of the stopcock port where the evd was attached to the transducer, rendering the evd incapable of measuring intracranial pressure (icp).The evd was then clamped in two places: proximally nearest to the patient and distally at the distal stopcock to prevent exposure.Plan for evd to be removed.Additional information has been requested.
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Manufacturer Narrative
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Additional information received on 04jun2019 in a medwatch form (uf/importer report #: (b)(4)) with the following information: there were several events related to the external ventricular drains (evd) leaking at the junction where evd was connected to the transducer set up.The evd were then clamped in two places: proximally nearest to the patient and distally at the distal stopcock to prevent exposure.The patients were immediately referred to the neuro surgery provider who changed the collection device on all of the patients.The patients did not have any adverse outcomes related to the device failures.
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Event Description
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N/a.
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Manufacturer Narrative
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The complaint unit was not returned for evaluation.No dhr review was possible since no lot number was reported.No samples were received for failure analysis.The complaint could not be confirmed.No further evaluation is possible at this moment and therefore, the root cause for this event is undetermined.
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Search Alerts/Recalls
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