inforMED
InjuryCCM

PLETHYSMOGRAPH, PRESSURE

Received Oct 21, 2015 · Event occurred Aug 6, 2015

Report 2021710-2015-01932 · MDR key 5163546

Device

Generic name

Masterscreen Paed-baby Body

Manufacturer

Carefusion

Model number

MS-BABY BODY TP

Catalog number

001-175550

Product problems

  • Device Displays Incorrect Message

Patient

17 MO

  • Fibrosis

Narrative

Additional Manufacturer Narrative

RESULTS OF INVESTIGATION: THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED THE PRINT MSB48907 AND PERFORMED A FAILURE INVESTIGATION. THE DEVICE WORKED AS EXPECTED TO SERVICE SPECIFICATIONS AND THE FAILURE COULD NOT BE DUPLICATED. THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED A SECOND PRINT MSB48907 AND AN INVESTIGATION WAS COMPLETED. THE DEVICE WORKED AS EXPECTED TO SERVICE SPECIFICATIONS AND THE FAILURE COULD NOT BE DUPLICATED.

Additional Manufacturer Narrative

A FUNCTIONAL CHECK WAS DONE BY A CAREFUSION FAILURE ANALYSIS TECHNICIAN. THE COMPUTER WAS BOOTED UP AND THE DEVICE MANAGER WAS ACCESSED. THE VIDEO CARD WAS RECOGNIZABLE TO THE SYSTEM. THERE WERE NO PROBLEMS FOUND ON THE VIDEO CARD AND THE VIDEO CARD IS FUNCTIONING PROPERLY. IN CONCLUSION, THE CUSTOMER¿S COMPLAINT OF ¿WINNOV CARD NOT BEING RECOGNIZED¿ AND SHUTTER PROBLEM COULD NOT BE CONFIRMED. FAILURE ANALYSIS INDICATED THERE WAS NO DAMAGE OR BURNT COMPONENTS ON VIDEO CARD AND THE OPERATIONAL/FUNCTIONAL CHECK WAS NORMAL. THERE WAS NO PROBLEM FOUND. AS A RESULT OF NOT BEING ABLE TO DUPLICATE THE CUSTOMER¿S EXPERIENCE, A CONCLUSIVE ROOT CAUSE COULD NOT BE IDENTIFIED.

Additional Manufacturer Narrative

RESULTS OF INVESTIGATION: THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED THE MASTERSCREEN BABY BODY BOX AND PERFORMED A FAILURE INVESTIGATION. THE ROOT CAUSE OF THE ISSUE WAS FOUND TO BE INCORRECT ASSEMBLY OF THE DEVICE. THE WIRING OF V1 AND V2 WAS WRONG, THERE WAS A BAD SOLDERING POINT ON V2 AND THE SQUEEZE SENSORS HAD NO ELECTRICAL ALIGNMENT.

Additional Manufacturer Narrative

CAREFUSION FILE IDENTIFICATION NUMBER (B)(4). ANY ADDITIONAL INFORMATION RECEIVED FROM THE CUSTOMER WILL BE INCLUDED IN A FOLLOW-UP REPORT. (B)(4). THE DEVICE HAS NOT BEEN RECEIVED BY CAREFUSION.

Description of Event or Problem

IT WAS REPORTED BY THE CUSTOMER THAT THE SHUTTER BALLOON TEST FAILED AND RECEIVED A "SHUTTER PRESSURE ZERO FAIL" MESSAGE AND THE DATA WAS LOST FOR THE PATIENT. AFTER TROUBLESHOOTING WITH FIELD SERVICE ENGINEER (FSE) IT IS UNKNOWN IF THE REPORTED ISSUE HAS BEEN CORRECTED. THE CUSTOMER STATED DUE TO THE EQUIPMENT BEING NON-OPERATIONAL THEY HAD TO PERFORM A MORE INVASIVE DIAGNOSTIC TEST (BRONCHOSCOPY) AND THE LOSS OF DATA FROM THE PULMONARY FUNCTION TEST CONTRIBUTED TO A DELAY IN THE PATIENT'S DIAGNOSIS.

Additional Manufacturer Narrative

RESULTS OF INVESTIGATION: THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED THE PAEDIATRIC PNEUMOTACH AND PERFORMED A FAILURE INVESTIGATION. THE DEVICE WORKED AS EXPECTED TO SERVICE SPECIFICATIONS AND THE FAILURE COULD NOT BE DUPLICATED. THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED A SECOND COMPONENT TO EVALUATE, THE MS PAEDIATRIC HANDLE, AND AN INVESTIGATION WAS COMPLETED. IT WAS DETERMINED THAT THIS WAS THE WRONG COMPONENT FOR THE PRIMARY DEVICE. THE WRONG PART NUMBER WAS ORDERED FOR THE PRODUCT SO THE COMPONENT WAS INCOMPATIBLE FOR PROPER USAGE AND COULD NOT BE INSTALLED PROPERLY.

Additional Manufacturer Narrative

RESULTS OF INVESTIGATION: THE CAREFUSION FAILURE ANALYSIS LAB RECEIVED THE BOARD SSB AND PERFORMED A FAILURE INVESTIGATION. THE DEVICE WAS RECEIVED IN A DAMAGED CONDITION AND WHEN TESTED, THE COMPONENT WAS HOT AND NON-FUNCTIONING. NO FURTHER INVESTIGATION WAS POSSIBLE.