inforMED
MalfunctionBXK

NA

Received Sep 28, 2001

Report 2518435-2001-00003 · MDR key 353746

Device

Generic name

Calibration Gas Standard

Model number

*

Catalog number

536053

Lot number

116617

Product problems

  • Calibration Error
  • Gas Output Problem
  • Mislabeled
  • Inaccurate Delivery

Patient

NA

  • Unknown (for use when the patient's condition is not known)

Narrative

Description of Event or Problem

MEDICAL GRAPHICS CORP'S (MGC) "QA/RA" MGR, CONTACTED SCOTT MEDICAL PRODUCTS' QUALITY ENGINEER TO REPORT A PROBLEM WITH A CALIBRATION GAS STANDARD. BASED ON AN EQUIPMENT SERVICE CALL AT THE USER FACILITY, MGC HAD DETERMINED THAT A CALIBRATION GAS STANDARD, LOT NO. 116617, WAS DEFECTIVE. THE CALIBRATION GAS STANDARD WAS LABELED AS 21% OXYGEN, HOWEVER IT WAS DETERMINED TO BE APPROXIMATELY 19.7% OXYGEN. MGC WAS CALLED TO SERVICE THE CARDIO2 EQUIPMENT (CARDIOPULMONARY EXERCISE SYSTEM) BECAUSE THE PULMONARY GROUP BELIEVED THAT IT WAS NOT PROVIDING CORRECT VO2 VALUES. SMP ANALYZED A CYLINDER FROM THE SAME MANUFACTURING LOT AND CONFIRMED THE VALUE OF THE OXYGEN CONCENTRATION TO BE APPROX 19.7%. MGC COMPLETED EXPERIMENTS TO DETERMINE THE IMPACT OF USING THE 19.7% OXYGEN CALIBRATION GAS ON THE VO2 VALUES. MGC FOUND THE VALUES OF THE VO2 TO BE APPROX 21% HIGHER THAN THE "TRUE" VALUE.

Remedial action

  • Recall