inforMED
MalfunctionMQS

CRRT

Received Apr 18, 2012 · Event occurred Dec 28, 2011

Report 2564969 · MDR key 2564969

Device

Generic name

Crrt

Model number

PRISMAFLEX

Catalog number

*

Lot number

*

Product problems

  • Device Displays Incorrect Message

Patient

37 YR

  • Blood Loss

Narrative

Description of Event or Problem

IN THE MORNING THE CONTINUOUS RENAL REPLACEMENT (CRRT) MACHINE ALARMED. RN CHECKED THE ALARM TO FIND THAT THE SCREEN SAID "SYSTEM MALFUNCTION." NO CHOICES WERE GIVEN ON THE SCREEN. THE INSTRUCTIONS STATED TO RETURN THE BLOOD BY CRANK. RN DID NOT DO SO DUE TO THE RISK OF CLOTS BEING RETURNED TO THE PATIENT. PATIENT WAS DISCONNECTED FROM THE MACHINE. MACHINE WAS TURNED OFF, THEN BACK ON, AND AT THAT POINT THE RN WAS ABLE TO DOWNLOAD DATA TO THE DATA CARD.