Draeger Medical Systems, Inc. Jaundice Meter JM-103 and Jaundice Meter JM-105 Recalled Due to Misinterpretation of Display Messages for Out of Range Values

PUBLISHED: Jun 22, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals, Medical Office, Rural Health Clinics

The FDA has identified this as a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death.

Draeger Medical Systems, Inc. is recalling their Jaundice Meter JM-103 and JM-105 models which are used to measure bilirubin in newborn infants.

The meters are being recalled because users have misinterpreted display messages that have resulted in serious injuries. Specifically, the JM-103 Meter displays three blinking dashes (- - -) and the JM-105 Meter displays dash-zero-dash (-0-) when the bilirubin level in the patient is higher than the maximum level of detection (>340µmol or 20mg/dl). Measurement of high bilirubin indicates a need for immediate medical evaluation. Some users have interpreted the two display messages as indicating a "low" or "zero" value instead of high bilirubin levels. When this happens, treatment may be delayed or not offered, which could lead to brain damage and possibly death in some newborns/infants.

The out of range display is visible; however, the interpretation of the reading is not intuitive or clear. Uncertainty about the out of range indication on the Jaundice meter could cause a delay of treatment in a patient with hyperbilirubinemia.

RECALLED PRODUCT

Name: Jaundice Meter JM-103 and Jaundice Meter JM-105

Product code: MQM

Model numbers: JM-103: MU20606; JM-105: MU20105

Manufacturing Dates: JM-103 June 2008 to August 2017, JM-105 September 2013 to April 2018

Distribution Dates: JM-103 July 2008 to September 2017, JM-105 October 2013 to April 2018

Devices Recalled in the U.S.: JM-103: 2449; JM-105: 2063

WHAT TO DO

Draeger Medical issued an Urgent Medical Device Safety Notice to customers with the following instructions:

  • Ensure that all JM-105 and JM-103 devices are labeled per the instructions provided by the firm in a timely manner. Draeger provided their users with labels which should be applied directly onto the meter to remind the user of the meaning of the blinking (---) for the JM-103 model, and (-0- ) for the JM-105 model. The label has a picture of the out of range display messages as they appear on the meter with three blinking (---) for JM-103 or (-0-) for JM-105: and the interpretation of the messages stating "Measurement out of range >340µmol/L/20mg/dL."
  • Provide training to all users in the clinical environment on how to use the equipment, and ensure that they understand that this is a screening device not to be used as a standalone diagnostic device.
  • Perform a blood test if they obtain a bilirubin measurement that is above the device maximum value of 20mg/dL or 340µmol.
  • Complete and return the Customer Reply card sent by the firm.
  • Look for a separate communication letter from Draeger which notifies those using JM-105 about the availability of upgraded software and provides instructions for sending the device to the firm if they choose to have the upgrade implemented.

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