inforMED
MalfunctionDTW

S3 BUBB DET SENSOR, LOW LEVEL II

Received Nov 28, 2019 · Event occurred Oct 2, 2019

Report 9611109-2019-00923 · MDR key 9390402

Device

Generic name

Monitor And/or Control, Level Sensing, Cardiopulmonary Bypass

Model number

23-27-40

Product problems

  • Defective Alarm
  • Defective Alarm

Patient

Not reported

  • No Patient Involvement
  • No Patient Involvement

Narrative

Additional Manufacturer Narrative

THERE WAS NO PATIENT INVOLVEMENT. LIVANOVA (B)(4) MANUFACTURES THE S3 BUBBLE DET SENSOR, LOW LEVEL II. THE INCIDENT OCCURRED IN (B)(6). THROUGH FOLLOW-UP COMMUNICATION LIVANOVA (B)(4) LEARNED THAT THE USER CHECKED THE SENSOR PAD AS FIRST, THEN HE USED A SENSOR FROM ANOTHER MACHINE TO RESOLVE THE ISSUE. A NEW LEVEL SENSOR WAS SHIPPED TO THE HOSPITAL. THROUGH FURTHER FOLLOW-UP COMMUNICATION LIVANOVA (B)(4) LEARNED THAT THE SENSOR WAS PROPERLY CONNECTED. IF ANY ADDITIONAL INFORMATION PERTINENT TO THE REPORTED EVENT IS RECEIVED, IT WILL BE PROVIDED IN A SUPPLEMENTAL REPORT.

Description of Event or Problem

LIVANOVA (B)(4) RECEIVED A REPORT THAT A S3 BUBBLE DET SENSOR, LOW LEVEL II DID NOT ALARM WHEN RESERVOIR WAS EMPTY DURING SETUP. THERE WAS NO PATIENT INVOLVEMENT.

Remedial action

  • Other