inforMED
InjuryBTM

VITAL SIGNS

Received Oct 18, 2021 · Event occurred Sep 12, 2021

Report 12646685 · MDR key 12646685

Device

Generic name

Ventilator, Emergency, Manual (resuscitator)

Model number

5102RVW

Catalog number

5102RVW

Product problems

  • Increase in Pressure
  • Structural Problem

Patient

Not reported

  • Unspecified Tissue Injury
  • Unspecified Tissue Injury

Narrative

Description of Event or Problem

WE HAD A SERIOUS SAFETY EVENT IN OUR PEDIATRIC ICU THAT INVOLVED THE USE OF A FLOW-INFLATING MANUAL RESUSCITATOR BAG. THE PRESSURE RELEASE VALVE WAS LEFT CLOSED WHILE GIVING BREATHS, CAUSING HIGH PRESSURES TO ENTER THE LUNGS WHICH RESULTED IN INJURY TO THE PATIENT. MANUFACTURER RESPONSE FOR BREATHING CIRCUIT, JACKSON REES BREATHING CIRCUIT (PER SITE REPORTER): ALERTED THE MANUFACTURER, PROVIDED THE MEDSUN REPORT NUMBER AND THE DETAILS OF THE EVENT THAT THEY REQUESTED.