inforMED
MalfunctionGKT

SPECTRA OPTIA APHERESIS SYSTEM

Received Sep 6, 2019 · Event occurred Jul 5, 2019

Report 8968891 · MDR key 8968891

Device

Generic name

Separator, Automated, Blood Cell, Diagnostic

Manufacturer

Terumo Bct, Inc.

Catalog number

10220

Lot number

1904233130

Product problems

  • Leak/Splash

Patient

26645 DA

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

Narrative

Description of Event or Problem

APPROX. 2 MIN. INTO RINSEBACK OF THERAPEUTIC PLASMA EXCHANGE, NURSE NOTED THERE WAS LEAKAGE UNDER THE KIT'S CASSETTE NEAR WHERE THE RETURN TUBING EXITS OUT OF THE KIT'S CASSETTE. NURSE IMMEDIATELY CLAMPED THE RETURN LINE, THE DRAW LINE WAS ALREADY CLAMPED, STOPPED THE RINSEBACK, AND DISCONNECTED THE PATIENT FROM THE MACHINE. THE PHERESIS CATHETER WAS SOON REMOVED BY DOCTOR. TERUMO WAS CALLED AND WILL SEND SERVICE REP. TO CHECK THE MACHINE. THE KITS WITH THE SAME LOT NUMBER WERE SEQUESTERED AND THE AFFECTED KIT WAS PLACED IN A BIOHAZARD BAG AND WAS MAILED TO THE COMPANY.