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Home > Forms > Provincial Equipment Complaints

Provincial Equipment Complaints

Please complete the form below and keep any defective product.

To view progress status and resolutions for complaints, please visit the SCMSS Complaint Resolution tracker: SCM Product Complaints.

Provincial Equipment Complaint

"*" indicates required fields

Step 1 of 3

33%

Complaint #

END-USER INFORMATION

Name*

First Last

Phone*

(eg. (###) ###-####)

Email*

(eg. [email protected])

Facility*

Dept.*

DETAILS ABOUT THE PATIENT IMPACT

Date problem occurred (dd-mm-yyyy)*

DD dash MM dash YYYY

Product complaint(s) being reported*

IV Tubing

Pump

(choose all that apply)

Seriousness of incident*

Death

Life-threatening (actual)

None (issue notice upon removal from packaging)

Permanent damage or impairment of a body function or structure

Potential for death or serious deterioration in state of health

Unexpected medical or surgical intervention

Other

Other Serious Outcome

(please specify)

Was a safety event / incident report submitted?*

(e.g. RL)

Yes

Incident #*

(please specify)

Impact to patient*

(Interruptions examples are patient assessments, patient turns, dressing changes, support with activities of daily living, etc.)

(choose all that apply)

Delay in treatment

Emotional distress

Interruptions to clinical care due to time required to resolve alarms

Risk for drug reactions / side effects with too rapid of an infusion

Risk for infection / introduction of contaminants

Under dosing of ordered medication / fluids

Vital signs compromised

Other

Other Patient Impact

(please specify)

Action(s) taken*

Changed out pump (isolate and send to bioengineering department)

Followed B Braun tips to resolve alarms (Air-in-Line and Occlusion)

Repeated priming to clear air

Tubing replaced (triple bag and send to material management)

Other

(choose all that apply)

Other actions taken

(please specify)

Additional details

Medication / Fluid*

IV rate*

Other details

(Do not include identifiable patient details)

PRODUCT COMPLAINT DETAILS

Pump model information: B Braun Infusomat, model 8713051U

Pump serial or asset tag number

(e.g. KN#)

Problem with pump being reported

Alarm

Battery

Space Station

(choose all that apply)

Alarm events

Air in line – not visible and unresolved

Alarm High Pressure

Accuracy of fluid / medication delivery

Downstream Occlusion – unresolved

Upstream Occlusion – unresolved

Other

(please remember to complete the IV tubing section for any alarm events)

Other alarm events

(please specify)

Battery events

Did not charge

Failure

Other

Other battery events

(please specify)

Space Station events

(Do not include identifiable patient details)

Tubing sent to Materials Management?*

Yes

n/a

Product lot number

(found on packaging, if known)

Product expiry date (dd-mm-yyyy)

DD dash MM dash YYYY

IV-tubing product being reported

0.2 Filtered Cyto-Set (BB35414)

2 port set (BB490102)

2-port set (BB490102)

Blood tubing Y-set (BB490105)

Blood tubing Y-set ASV (BB363419)

Cyto-Set (BB835817SP)

Non-ported set (BB362035)

Straight blood set (8270066SP-26)

TPN Basic 0.2-micron filter set (BB490103)

TPN Basic 0.2-micron filter ASV set (BB363420)

TPN Lipids 1.2-micron filter set (BB470103)

UV-resistant 0.2-micron filter set (BB470119)

UV-resistant 0.2 micron filter ASV set (BB363410)

Other

Other product

(please specify)

Product problem

Backcheck valve malfunction

Broken port

Crimping

Difficulty spiking blood bag

Leaking

Missing part

Severed

Other

(choose all that apply)