inforMED

GAMBRO DIALYSIS MACHINE

Received Apr 3, 2008 · Event occurred Mar 9, 2008

Report 1031723 · MDR key 1031723

Device

Generic name

Dialysis Machine, Crrt

Model number

PRISMA

Catalog number

*

Lot number

*

Product problems

  • Alarm, audible
  • Output, high
  • Loss of Power
  • Repair

Patient

18 YR

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

Narrative

Description of Event or Problem

PATIENT ON GAMBRO PRISMA PUMP FOR CONTINUOUS RENAL REPLACEMENT THERAPY. PUMP SET FOR SAFETY LIMIT OF 130 CC OVER THREE HOUR PERIOD. PUMP ALARMED WHEN LIMIT OF 130 CC WAS REACHED, AND SHUT DOWN FOR EXCESSIVE REMOVAL OF FLUID. NEW PUMP OBTAINED AND PLACED ON PATIENT. THERE WAS NO PATIENT HARM FROM THIS EVENT. PUMP SENT TO BIO-MED TO BE CHECKED. BIO-MED REPLACED BLOOD PUMP INSERT, CHECKED PRISMA, CALIBRATED SCALES, CHECKED PRESSURES, AND PODS. PROBLEM COULD NOT BE DUPLICATED. WET TEST DONE AND MACHINE RETURNED TO SERVICE.