inforMED
MalfunctionONW

HOME HEMO COMBI SET FOR CANADA

Received Jan 12, 2022 · Event occurred Dec 21, 2021

Report 8030665-2022-00043 · MDR key 13234183

Device

Generic name

Hemodialysis System For Home Use

Catalog number

03-2932-6

Lot number

20LR01003

Product problems

  • Fluid/Blood Leak
  • Fluid/Blood Leak

Patient

66 YR · Female

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

THE PLANT INVESTIGATION IS IN PROCESS. A SUPPLEMENTAL MDR WILL BE SUBMITTED UPON COMPLETION OF THIS ACTIVITY.

Description of Event or Problem

IT WAS REPORTED THAT A COMBI SET BLOOD LEAK OCCURRED DURING THE BLOOD RETURN PROCEDURE OF A PATIENT'S HEMODIALYSIS (HD) TREATMENT. THE CLAMP ON THE SALINE LINE FAILED TO STAY CLOSED AND BLOOD REPORTEDLY BURST OUT. THERE WERE NO REPORTS OF ANY PATIENT HARM OR INJURY. THE PATIENT STATED THEY WOULD START USING BLOODLINES FROM A DIFFERENT LOT NUMBER. MULTIPLE ATTEMPTS WERE MADE TO OBTAIN ADDITIONAL INFORMATION, AND THUS FAR NO FURTHER DETAILS HAVE BEEN PROVIDED.

Description of Event or Problem

IT WAS REPORTED THAT A COMBI SET BLOOD LEAK OCCURRED DURING THE BLOOD RETURN PROCEDURE OF A PATIENT'S HEMODIALYSIS (HD) TREATMENT. THE CLAMP ON THE SALINE LINE FAILED TO STAY CLOSED AND BLOOD REPORTEDLY BURST OUT. THERE WERE NO REPORTS OF ANY PATIENT HARM OR INJURY. THE PATIENT STATED THEY WOULD START USING BLOODLINES FROM A DIFFERENT LOT NUMBER. MULTIPLE ATTEMPTS WERE MADE TO OBTAIN ADDITIONAL INFORMATION, AND THUS FAR NO FURTHER DETAILS HAVE BEEN PROVIDED.

Additional Manufacturer Narrative

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