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MalfunctionGKJ

COULTER® LH 750 SLIDEMAKER

Received Mar 27, 2013 · Event occurred Feb 26, 2013

Report 1061932-2013-00512 · MDR key 3024447

Device

Generic name

Spinner, Slide, Automated

Manufacturer

Beckman Coulter

Model number

NA

Catalog number

6605633

Lot number

NA

Product problems

  • Fluid/Blood Leak

Patient

Not reported

  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

THE AFFILIATE REPORTED THE CUSTOMER ALLEGED FLUID DETECTOR (FD) 6 ERRORS AND APPROXIMATELY FIVE MILLILITERS OF CLEAR FLUID LEAKED WITHIN THE INSTRUMENT FROM THE RIGHT SIDE TRAY INVOLVING THE COULTER LH 750 SLIDEMAKER. THE OPERATOR WAS WEARING PERSONAL PROTECTIVE EQUIPMENT (PPE) CONSISTING OF PROTECTIVE GLOVES AND A LABORATORY COAT AND DID NOT HAVE DIRECT CONTACT WITH THE FLUID. THERE WAS NO OPERATOR INJURY OR ADVERSE EFFECT ASSOCIATED WITH THIS EVENT. NO ERRONEOUS PATIENT RESULTS WERE GENERATED. THERE WAS NO PATIENT IMPACT. THE LABORATORY HAS AN EXPOSURE CONTROL/RISK MANAGEMENT PLAN IN PLACE. A BECKMAN COULTER FIELD SERVICE ENGINEER (FSE) WAS DISPATCHED TO EVALUATE THE INSTRUMENT.

Additional Manufacturer Narrative

THE FIELD SERVICE ENGINEER (FSE) OBSERVED THE PROBE RINSE SUPPLY LINE WAS ROUTED THROUGH PINCH VALVE VL20 INSTEAD OF PINCH VALVE VL19. THE FSE REROUTED THE TUBING THROUGH THE CORRECT PINCH VALVE AND RESOLVED THE FLUID LEAK ISSUE. THE INSTRUMENT CONFORMED TO THE MANUFACTURER'S PUBLISHED SPECIFICATIONS AND WAS RETURNED TO NORMAL OPERATION. (B)(4).