MAUDE Adverse Event Report: OGDEN MANUFACTURING PLANT OPTIFLUX F16NRE DIALYZER FINISHED ASSY; DIALYZER, CAPILLARY, HOLLOW FIBER

Model Number	0500306E
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	12/05/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The plant investigation is in process.A supplemental mdr will be submitted upon completion of this activity.
Event or Problem Description
A user facility registered nurse (rn) reported that an internal dialyzer blood leak occurred approximately thirty minutes into a patient¿s hemodialysis (hd) treatment.The blood leak was visually observed on the dialysate side of the dialyzer.There was no damage identified on the dialyzer.The machine, a gambro phoenix, alarmed with a blood leak.Blood leak test strips were used and they tested positive for the presence of blood.The patient¿s estimated blood loss (ebl) was approximately 260 ml.The rn confirmed there was no patient injury, no adverse effects were experienced, and no medical intervention was required as a result of the event.The patient completed their treatment after being re-setup with new supplies on a different machine.The complaint device was reportedly available to be sent back to the manufacturer for a physical evaluation.
Additional Manufacturer Narrative
Plant investigation: the complaint device was returned to the manufacturer for physical evaluation.The corporate provided blood port caps and adapter caps were returned attached to the dialyzer.A gross visual evaluation of the dialyzer and dialyzer fibers was performed.There was blood contamination noted throughout the dialyzer.Multiple potted fiber fragments and broken fibers were identified throughout the entire length of the dialyzer.The opposing ends of the fibers could not be isolated due to the quantity of broken fibers.Further visual examination of the sample did not identify any other damage or irregularities (aside from the damaged fibers).Due to the visualization of broken fibers within the dialyzer housing, a leak test was not performed.A production records review was performed on the reported lot.An investigation of the device history records (dhr) was then conducted by the manufacturer.There was no indication of product nonacceptance, deviation, non-conformance, rework, labeling or process control failure during the manufacturing process which could be associated with the reported event.The lot met all release criteria.The cause for the multiple broken fibers on the dialyzer is unknown.The dialyzer manufacturing process has multiple controls in place to reject product with an internal leak/broken fiber during production.Dialyzers with broken fibers, as seen in the returned sample, would have been rejected by these controls.Review of the production records did not show that similar issues occurred during lot manufacture.No other customers have reported any complaints of any type against this lot number.No similar damage has been seen on returned dialyzers from any lot number in the previous 18 months of product manufacture.However, due to the identification of multiple potted fiber fragments and broken fibers, the investigation into the complaint was able to confirm the reported event.

• Brand Name: OPTIFLUX F16NRE DIALYZER FINISHED ASSY
• Common Device Name: DIALYZER, CAPILLARY, HOLLOW FIBER
• Manufacturer (Section D): OGDEN MANUFACTURING PLANT; director, site quality; 475 west 13th street; ogden UT 84404
• MDR Report Key: 9516970
• Report Number: 1713747-2019-00393
• Device Sequence Number: 11252832
• Product Code: FJI
• UDI-Device Identifier: 00840861100071
• UDI-Public: 00840861100071
• Combination Product (Y/N): N
• Initial Reporter State: OK
• Initial Reporter Country: US
• PMA/510(K) Number: K043244
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 02/11/2020

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 Expiration Date: 03/31/2022
• Device Model Number: 0500306E
• Device Catalogue Number: 0500306E
• Device Lot Number: 19CU01021
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/20/2019
• Device Age: MO
• Initial Date Received by Manufacturer: 12/09/2019
• Supplement Date Received by Manufacturer: 01/24/2020
• Initial Report FDA Received Date: 12/24/2019
• Supplement Report FDA Received Date: 02/11/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 56 YR
• Patient Weight: 84