inforMED
DeathFIL

FRESENIUS DUALYSIS DELIVERY SYSTEM

Received Mar 22, 2002

Report 2937457-2002-00020 · MDR key 383986

Device

Generic name

Hemodialysis Machine

Model number

2008K

Catalog number

NA

Lot number

NA

Product problems

  • Device Alarm System
  • Source, detachment from

Patient

UNKNOWN

  • Cardiopulmonary Arrest
  • Death
  • Blood Loss

Narrative

Description of Event or Problem

A DIALYSIS FACILITY REQUESTED TO HAVE A MACHINE EVALUATED AFTER AN ADVERSE EVENT. IT WAS REPORTED THAT THE VENOUS NEEDLE WAS PULLED OUT FROM THE PT'S ACCESS DURING A HEMODIALYSIS TREATMENT. THERE WAS REPORTEDLY NO MACHINE ALARM. ESTIMATED BLOOD LOSS WAS TWO LITERS. PT CODED AND EXPIRED. VENOUS WIDTH SELECTED WAS 200. NO OTHER INFO IS AVAILABLE.