Field Safety Notice Olympus UHI-4 High Flow Insufflation Unit (ICN 2375)
Important Customer Notice Update
Ref: 2023/2375
ICN Number: 2375
Update:
- Olympus has released an update to the Field Safety Notice relating to UHI-4 High Flow Insufflation Unit products.
- Olympus has become aware of an increased trend from both repairs and customer complaints of the ‘UHI-4 stopping CO2 gas supply with the front panel LED turning off’. Based on the analysis of customer complaints, the issue was determined to be associated with a control board, or CR board, pressure sensor circuit failure.
- To maximize patient safety and mitigate any potential risk to patient health, Olympus will replace the CR board of UHI-4 devices which were manufactured more than five years ago.
Next Steps:
- Customers should continue to quarantine the product unless their facility does not have or is unable to obtain an alternative device and chooses to use the UHI-4 with extreme caution, after weighing the potential benefits of the procedure verses the potential risk to health over insufflation described below until:
- For units five years and older – The unit will receive both the software update and a CR board replacement
- For units under five years – The unit will receive the software update only.
- Olympus will contact customers based on device age and parts availability to schedule a repair of the CR board. Olympus will be prioritizing customers who have continued to use the UHI-4.
- Olympus will contact customers in late summer of 2024 regarding the software update to address the over insufflation.
- As always, Olympus requests that customers report complaints, including any injuries during the procedure with UHI-4 to concerns@olympus.com
- Please also submit a product complaint form through the NHS Supply Chain link provided –https://www.supplychain.nhs.uk/contact/submit-product-complaint
Alert:
- Olympus has released a Field Safety Notice relating to UHI-4 High Flow Insufflation Unit products.
- There are three product codes affected.
- Olympus has become aware of patients experiencing complications from over-insufflation where UHI-4s were used. Clinical complications cited from Olympus include “short cardiac arrest gas embolism and one death during surgical procedures where the UHI-4 has been used.
- These complications may have been due to over-insufflation of the abdominal cavity resulting from the use of the UHI-4 during the procedures. This includes events where the device was reported to not alarm or otherwise notify the user and events where the device did not relieve the over-insufflation to the set pressure.
Products Affected:
- The affected products are not available via the NHS Supply Chain catalogue.
- These capital products are purchased via OJEU (Official Journal of the European Union) compliant orders using our Unique Reference Number (URN) requested from the buying team.
Material ID | Model | Description | UDI | Serial Numbers |
N3829650 | UHI-4 | Insufflator, UHI-4, 220-240V | 04953170435881 | All |
N3829660 | UHI-4 | Insufflator, UHI-4, 220-240V | 04953170324154 | All |
N3829670 | UHI-4 | Insufflator, UHI-4, 220-240V | 04953170324161 | All |
Next Steps
- See our Downloads ▼ section to access the full instructions in the Field Safety Notice and share them with all users of the affected products.
- Follow local organisational risk assessment.
- You should take the following actions:
- Discontinue use of the UHI-4 until the root cause investigation is completed
- Devices should be quarantined and marked appropriately by your site to prevent usage
- If your facility does not have alternatives or is unable to obtain alternatives, you may choose to use the UHI-4 while exercising extreme caution, after weighing the potential benefits of the procedure versus the potential risk to the health of over-insufflation.
- If your organisation determines option 3, please ensure staff are made aware of Pages 2 and 3 of the Field Safety Notice CONSIDERATIONS FOR PROVISIONAL USAGE and is applied in addition to patient procedure risk assessment.
- Olympus requests that you report complaints, including any injuries associated with over-insufflation during the procedure with UHI-4, to Olympus.
- Please report complaints to concerns@olympus.co.uk
- If you require additional information, please do not hesitate to contact the supplier at ra@olympus.co.uk
- If you have any further questions, please contact your local NHS Supply Chain Hospital Care team.