MAUDE Adverse Event Report: MASIMO - 52 DISCOVERY RAD-67 SPOT CHECK PULSE CO-OXIMETER

Model Number	25870
Medical Device Problem Code	High Readings (2459)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	01/01/1901
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional manufacturing narrative: attempts have been made to obtain the product.The product has not been returned to masimo to allow an analysis to be performed.If the product is returned for evaluation or new information is obtained, a follow up report will be submitted.
Event or Problem Description
The customer reported that the device provided high readings.No consequences or impact to patient were reported.
Additional Manufacturer Narrative
Additional manufacuring narrative: the returned device was evaluated.During evaluation the device passed all visual and functional testing.During simulation testing, the device passed manual and preset conditions and provided accurate measurements.The unit was found to visually and audibly alarm during alarm conditions.The unit was determined to be functioning as designed., corrected data: d11 concomitant products updated from a blank field to "rainbow m20-04, patient cable, rnbw super dci-mini sc 400".
Event or Problem Description
The customer reported that the device provided high readings.No consequences or impact to patient were reported.

• Brand Name: RAD-67 SPOT CHECK PULSE CO-OXIMETER
• Common Device Name: OXIMETER
• Manufacturer (Section D): MASIMO - 52 DISCOVERY; 52 discovery; irvine CA 92618
• MDR Report Key: 9188689
• Report Number: 3011353843-2019-00091
• Device Sequence Number: 2104947
• Product Code: DQA
• UDI-Device Identifier: 00843997012812
• UDI-Public: 00843997012812
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K182887
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Other Health Care Professional
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/23/2019

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: 25870
• Device Catalogue Number: 9794
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/11/2019
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 09/23/2019
• Supplement Date Received by Manufacturer: 12/28/2019
• Initial Report FDA Received Date: 10/14/2019
• Supplement Report FDA Received Date: 01/21/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: M20-04 PATIENT CABLE; SUPER DCI-MINI SC 400