inforMED
MalfunctionKOC

CRIT-LINE®

Received Jul 21, 2022 · Event occurred Jun 24, 2022

Report 15074307 · MDR key 15074307

Device

Generic name

Accessories, Blood Circuit, Hemodialysis

Model number

CL10041021

Catalog number

CL10041021

Lot number

21KR01001

Product problems

  • Break
  • Fluid/Blood Leak

Patient

26280 DA · Male

  • Hemorrhage/Blood Loss/Bleeding
  • Hemorrhage/Blood Loss/Bleeding

Narrative

Description of Event or Problem

SENSOR BROKE APART WHILE THE PATIENT WAS ON THE HD MACHINE CAUSING A BLOOD LEAK. HAD WE NOT NOTICED IMMEDIATELY AND STOPPED THE BLOOD PUMP, PATIENT WOULD HAVE MAJOR BLOOD LOSS AS THIS WAS LEAK IN THE CIRCUIT WITH A BLOOD PUMP AT 400 ML/MIN RUNNING. MINOR BLOOD LOSS TO PATIENT. THE FOLLOWING DAY, ANOTHER SENSOR WAS FOUND NOT TO BE BONDED TOGETHER PROPERLY- CAUGHT PRIOR TO USE.

Description of Event or Problem

SENSOR BROKE APART WHILE THE PATIENT WAS ON THE HD MACHINE CAUSING A BLOOD LEAK. HAD WE NOT NOTICED IMMEDIATELY AND STOPPED THE BLOOD PUMP, PATIENT WOULD HAVE MAJOR BLOOD LOSS AS THIS WAS LEAK IN THE CIRCUIT WITH A BLOOD PUMP AT 400 ML/MIN RUNNING. MINOR BLOOD LOSS TO PATIENT. THE FOLLOWING DAY, ANOTHER SENSOR WAS FOUND NOT TO BE BONDED TOGETHER PROPERLY- CAUGHT PRIOR TO USE.