inforMED
MalfunctionCBF

HYPERBARIC VENTILATOR

Received Feb 1, 2013 · Event occurred Jan 4, 2013

Report 2020676-2013-00001 · MDR key 2971114

Device

Generic name

Ventilator, Continuous, Facility Use

Model number

500A

Catalog number

3000

Product problems

  • Pressure Problem

Patient

Not reported

  • No Information

Narrative

Additional Manufacturer Narrative

THE REPORTED FAILURE WAS VERIFIED AND DUPLICATED. EVALUATION OF THE DEVICE TOOK PLACE BY THE MANUFACTURER. THE EXHALATION KNOB TURNS PAST THE STOP DUE TO THE KNOB BEING SET AT THE INCORRECT HEIGHT. THIS ALLOWED THE KNOB TO SLIP PAST THE STOP PIN. FURTHER TESTING FOUND THAT THE MAXIMUM INHALATION AND EXHALATION TIMES AND THE MINIMUM INHALATION TIME WERE OUT OF SPECIFICATION. THE TIDAL VOLUME AT 1000 IS OUT OF SPECIFICATION AT 2.0ATA, 2.5ATA AND 3.0ATA. THE IMMEDIATE CAUSE OF THE INHALATION AND EXHALATION TIMES AND TIDAL VOLUME BEING OUT OF SPECIFICATION WAS A MALFUNCTIONING FLUIDIC INTERFACE.

Description of Event or Problem

A BIOMEDICAL TECHNICIAN FOR THE HOSPITAL REPORTED THAT DURING A SCHEDULED PERFORMANCE MAINTENANCE TEST IT WAS FOUND THAT THE VENTILATOR PRESURE DID NOT COMPENSATE FOR THE CHAMBER PRESSURE.