inforMED
MalfunctionLHC

WARMFLO

Received Mar 5, 2008

Report 2936999-2008-00113 · MDR key 1008269

Device

Generic name

Fluid Warming Cassette

Manufacturer

Henequen

Model number

WF-100 CASSETTE

Catalog number

WF-100

Product problems

  • Thermal Decomposition of Device
  • Device Emits Odor

Patient

Not reported

  • Unknown (for use when the patient's condition is not known)

Narrative

Description of Event or Problem

A WARMFLO WF588 FLUID WARMER AND WARMFLO WF-100 CASSETTE WERE BEING USED DURING A TRANSFUSION. DURING THE PROCEDURE A NURSE NOTICED A BURNING SMELL COMING FROM THE FW588. SHE STOPPED THE PROCEDURE AND EXAMINED THE CASSETTE AND NOTICED THE BLOOD WAS VERY DARK. NO PT INFO WAS PROVIDED.

Additional Manufacturer Narrative

IN THE MORNING AFTER THE EVENT, THE NURSE SENT THE WARMFLOW 588 FLUID WARMER TO THE HEAD OF THE MEDICAL TECH DEPT. HE REPORTED IT WAS THEN OPENED, EXAMINED, AND TESTED AND IT FUNCTIONED PROPERLY. COVIDIEN HAS REQUESTED THE WARMFLO 588 FLUID WARMER, AND THE WARMFLO WF-100 CASSETTE BE RETURNED FOR FAILURE INVESTIGATION, HOWEVER, THE CASSETTE USED WAS SENT TO A LOCAL LAB FOR EVAL. THIS INVESTIGATION IS CURRENTLY IN PROGRESS. WHEN THE RESULTS FROM THE LAB CAN BE REVIEWED BY OUR CLINICAL SPECIALIST, AND/OR ANY NEW SIGNIFICANT INFO IS OBTAINED, A FOLLOW-UP REPORT WILL BE FILED.