Puritan Bennett 980 Universal Ventilator System 의 안전성 경고

Safety alert

2017-09-19

2017-09-19

Hong Kong

DH

https://www.mdco.gov.hk/english/safety/recalls/recalls_20170919b.html

Medical device safety alert: medtronic puritan bennett 980 universal ventilator system the therapeutic goods administration (tga) of australia has issued a safety alert concerning puritan bennett 980 universal ventilator system, manufactured by medtronic. consumers and health professionals are advised that the tga has suspended the covidien/medtronic pb980 ventilator from the australian register of therapeutic goods (artg) for six months. this action has been taken as the tga is concerned that, until rectified, use of these ventilators raises a potential risk of death, serious injury or illness. pb980 ventilators provide respiratory support to patients in intensive care units or other high-level care wards within hospitals and during intra-hospital transport. these ventilators have been the subject of several complaints relating to the screen going blank, graphical user interface (gui) becoming unresponsive, unexpected shutdowns or restarts, false triggering, serial number mismatch and usb failures. additionally, the manufacturer has identified issues with accuracy when used with newborn infants (neomode). some of these issues had been progressively addressed in a series of software updates during 2015 and 2016. however, further incident reports were received subsequently and testing by tga laboratories in 2017 found a range of serious issues persisted. the tga sought expert advice from the advisory committee on medical devices (acmd) regarding the clinical risk of the accuracy of ventilation observed by the tga's laboratories, the clinical risk of the issues with the device's user interface, and the safety of the performance specifications published in the operator's manual. following its meeting on 24 august 2017, acmd advised the tga that: the issues with the user interface, including the loss of interactivity with control settings, which were observed by the tga laboratories and in device incident reports, were an unacceptable risk to patients for a device intended to be used in a critical care environment. the discrepancies in ventilation accuracy observed by the tga laboratories were an unacceptable risk to paediatric patients. the tolerances for variation in ventilation therapy that are reported in the operator's manual were not suitable for paediatric patients. in addition, the committee believed it would be difficult to set conditions under which the use of this device may be safe for paediatric patients, that is a patient weighing less than 35 kg. the tga has notified state and territory health authorities, private hospitals and clinics of the decision to suspend the device from the register. tga recommends that health professionals consider not using the device where suitable alternatives are available. according to the local supplier, the affected products are distributed in hong kong. for details, please refer to the tga website: https://www.Tga.Gov.Au/alert/puritan-bennet-980-series-ventilator if you are in possession of the affected product, please contact your supplier for necessary actions. posted on 19 september 2017.