inforMED
MalfunctionFPL

VOYAGER TRANSPORT INCUBATOR

Received Dec 20, 2018 · Event occurred Dec 6, 2018

Report 8183858 · MDR key 8183858

Device

Generic name

Incubator, Neonatal Transport

Catalog number

20035655

Product problems

  • Failure to Deliver
  • Gas/Air Leak

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

NEONATAL TRANSPORT ISOLETTE/OXYGEN DELIVERY-BLENDER DEVICE FAILED DURING (AND PRIOR TO) NEONATAL INTENSIVE CARE UNIT (NICU) TRANSPORT. THIS CAUSED INABILITY TO BRINGING PATIENT BACK ON A LOW FIO2/LOW FLOW NASAL CANNULA, WHICH WAS CURRENT THERAPY ORDERED. HISTORY OF EVENT: BLENDER ALARM NOTED UPON INITIAL ASSESSMENT AROUND 10:00 AM-PRIOR TO LEAVING THE FACILITY ON TRANSPORT. THREE ADDITIONAL RTS EVALUATED THE BLENDER ALARM AND CAME TO THE CONCLUSION THAT BIOMED NEEDED TO BE INVOLVED. BIOMED WAS NOT IMMEDIATELY AVAILABLE, SO ENGINEERING CAME IMMEDIATELY AND THEN WAS ABLE TO INVOLVE BIOMED AFTER FURTHER ASSESSMENT. ONE OF THE AIR REGULATORS WAS FOUND TO HAVE A LARGE LEAK NO MATTER WHAT TROUBLESHOOTING WAS COMPLETED.