Catalog Number 8604700 |
Device Problems
Device Alarm System (1012); Gas Output Problem (1266); Failure to Deliver (2338)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 08/23/2019 |
Event Type
malfunction
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Manufacturer Narrative
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The investigation has just started; results will be provided in a follow-up report.
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Event Description
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It was reported that there was an apnea pressure and a ventilator failure alarm during a case.There was no injury reported.
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Manufacturer Narrative
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The particular device is 14 years old.It was checked on-site by a dräger technician who wasn't able to duplicate the error.The device was tested in detail but it exhibited no deviations during these tests.It was returned to use with no further problems reported since then.The log file was evaluated by the manufacturer.The reported issue can be confirmed in general - there are entries for the period in question which are pointing to occurrence of motor speed deviations.The motor is equipped with a collector disc and carbon brushes - these parts are subject to wear and tear.It sounds reasonable after such a long time of use that the carbon brushes have reached wear and tear limit and sporadically loose the electric contact to the collector which results in speed fluctuations.The system is constantly monitoring the measured actual speed against the expected one and is designed to shut down automatic ventilation if the divergence exceeds a certain threshold.This behavior is intended to protect the ventilator unit from serious damages.The shut down is accompanied by a corresponding alarm, manual ventilation remains possible.It was recommended to the customer to let draeger check the motor and to replace it if considered necessary.The motor is designed for a lifetime of 10 years; the exhibition of wear and tear related malfunction after almost 15 years can be considered well-acceptable.
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Event Description
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Please refer to initial mfr.Report.
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Search Alerts/Recalls
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