OtherFII
PHOENIX
Received Dec 23, 2008 · Event occurred Nov 10, 2008
Report 2087532-2008-00100 · MDR key 1317918
Device
Generic name
Hemodialysis Equipment
Manufacturer
Gambro DascoModel number
PHOENIXCatalog number
6023006700
Lot number
NA
Product problems
- Disconnection
- Fluid/Blood Leak
Patient
UNKNOWN
- Burn(s)
- Burn, Thermal
Narrative
Description of Event or Problem
GAMBRO RECEIVED A REPORT THAT DURING A HEAT CITRIC DISINFECTION PROCEDURE, THE BICARBONATE CONCENTRATE TUBING CAME OFF THE BLUE MALE CONCENTRATE CONNECTOR ASSEMBLY ON THE LOWER FRONT PANEL OF A PHOENIX MACHINE. FOLLOWING THIS DISCONNECTION, A NURSE WAS BURNED BY HOT WATER THAT SPRAYED ONTO HER LEG. THE NURSE WAS TREATED ACCORDING TO THE UNIT'S POLICY (SHE WAS NOT TREATED IN THE EMERGENCY ROOM OR SEEN BY A PHYSICIAN). THE NURSE RETURNED TO WORK THE FOLLOWING DAY. THE PHOENIX MACHINE REMAINS IN SERVICE.