inforMED
MalfunctionNPF

SMART MONITOR 2PS

Received Feb 15, 2018

Report 3006182632-2018-00003 · MDR key 7274410

Device

Generic name

Infant Apnea Monitor

Manufacturer

Circadiance, Llc

Model number

1014557

Catalog number

1014557

Product problems

  • Device Dislodged or Dislocated
  • Device Dislodged or Dislocated

Patient

24 MO

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

UPON REVIEWING THE NURSE CALL JACK IT IS OBVIOUS THAT THE JACK WAS PHYSICALLY DAMAGED. THE ONLY PLAUSIBLE EXPLANATION FOR THE LEVEL OF DAMAGE SEE ON THE JACK WOULD BE FOR THE UNIT TO HAVE SUFFERED AN IMPACT, SUCH AS BEING DROPPED, WITH THE NURSE CALL WYE CABLE CONNECTED TO THE NURSE CALL JACK. I SPOKE WITH THE COMPLAINANT ON 2/12/2018 AND SHE COULD NOT PROVIDE ANY SPECIFIC INFORMATION REGARDING THE DAMAGED NURSE CALL JACK. SHE ONLY INDICATED THAT NURSING WOULD SEND THE UNIT TO THE BIOMEDICAL DEPARTMENT NOTING THAT THE ALARM PORT WAS NOT WORKING. THE EXACT MECHANISM THAT NURSING USED TO DETERMINE THAT THE PORT WAS NOT FUNCTIONAL WAS NOT ABLE TO BE ASCERTAINED. WE ARE UNSURE IF THE DAMAGE WAS NOTICED WHEN THE UNIT WAS DROPPED OR AT SOME POINT IN TIME AFTER THE DAMAGE HAD OCCURRED. THIS FAILURE OF THE NURSE CALL JACK DOES NOT COMPROMISE THE ABILITY OF THE MONITOR TO MONITOR AND DETECT ALARM CONDITIONS. THE PRIMARY ALARM SYSTEM IN THE MONITOR REMAINED FUNCTIONAL. THE PROFESSIONAL USER MANUAL CLEARLY INDICATES THAT THE NURSE CALL FEATURE IS PROVIDED FOR CONVENIENCE AND SHOULD NOT BE RELIED UPON AS THE PRIMARY ALARM SYSTEM.

Description of Event or Problem

ON (B)(6) 2018 THE SPECIALTY HOSPITAL OF (B)(6) RETURNED A SMART MONITOR 2PS INFANT APNEA MONITOR MODEL NUMBER 1014557 (SERIAL NUMBER (B)(4)) WITH THE COMPLAINT THAT THE REMOTE ALARM PORT DOES NOT WORK. THE CIRCADIANCE SERVICE TECHNICIAN CONFIRMED THE COMPLAINT AND DOCUMENTED THAT THE NURSE CALL JACK IS DAMAGED. IF THE UNIT WAS USED WITH THE DAMAGED NURSE CALL JACK, THE MONITOR MAY NOT TRANSMIT AN ALARM TO THE HOSPITAL NURSE CALL SYSTEM.

Remedial action

  • Repair