MAUDE Adverse Event Report: COVIDIEN 840 VENTILATOR; VENTILATOR, CONTINUOUS, FACILITY USE

Model Number	840
Medical Device Problem Code	No Flow (2991)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	07/19/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The ventilator logged a background fault error code and the analog pcb (printed circuit board) was replaced.The type of investigation has not yet been determined.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
It was reported that during use the 840 ventilator stopped ventilation and safety valve went open.The patient was removed from the ventilator and placed on an alternate ventilator without harm.
Additional Manufacturer Narrative
Correction to evaluation codes method, result and conclusion.Device evaluation summary: service personnel (sp) inspected the ventilator and found a relevant code.Sp replaced the breath delivery (bd) central processing unit (cpu) printed circuit board (pcb) and analog (ai) pcb.The ventilator passed all test and calibrations per manufacturer specifications at the time of service.Only the ai pcb was returned to medtronic for further analysis.A visual inspection of the returned board shows no anomalies.The pcb was attached to the failure investigation (f.I) test ventilator and after 42 hours, unit generated a vent inoperative (inop) condition.The fault was isolated to component reference designator u53.The cause of the observed condition was determined to be the faulty component u53 on ai pcb.The event will be included in trending and monitoring.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: 840 VENTILATOR
• Common Device Name: VENTILATOR, CONTINUOUS, FACILITY USE
• Manufacturer (Section D): COVIDIEN; micheal collins rd mervue; galway
• MDR Report Key: 8902934
• Report Number: 8020893-2019-00157
• Device Sequence Number: 11249902
• Product Code: CBK
• UDI-Device Identifier: 10884521076907
• UDI-Public: 10884521076907
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K151252
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 12/19/2019

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: 840
• Device Catalogue Number: 4-840120DIJJ-NJ
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/28/2019
• Initial Date Received by Manufacturer: 07/24/2019
• Supplement Date Received by Manufacturer: 12/12/2019
• Initial Report FDA Received Date: 08/16/2019
• Supplement Report FDA Received Date: 12/19/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1