Z-2151-2025Class II

Covidien Nellcor Bedside SpO2 Patient Monitoring System: REF: PM100N, 10005941, DLPM100N, DL10005941...

Name: Z-2151-2025 Covidien Nellcor Bedside SpO2 Patient Monitoring System: REF: PM100N, 10005941, DLPM100N, DL10005941...
Creator: Covidien
Published: 2025-06-23
License: https://open.fda.gov/license/

Medtronic, Inc. / initiated 2025-06-23 / Open, Classified / root cause: labeling and UDI

FDA source

Covidien began a recall of Covidien Nellcor Bedside SpO2 Patient Monitoring System: REF: PM100N, 10005941, DLPM100N, DL10005941, DSPM100N, 10005941-SG, DS10005941, 10005941J, 10005941JP... on 2025-06-23. FDA classified it as Class II and gives the reason as "Bedside SpO2 Patient Monitoring System alarms not heard/recognized, resulting in: treatment delay, lack of low oxygen saturation response, respiratory failure, arrhythmia. Highlighting operator's manual: 1)For patient...". As of 2026-09-10, the recall status on record is Open, Classified, and MDM tags the root cause as labeling and UDI.

Recall record

Recall number: Z-2151-2025
Classification: Class II
Status: Open, Classified
Initiated: 2025-06-23
Posted: 2025-07-21
Recalling firm: Medtronic, Inc.
Product: Covidien Nellcor Bedside SpO2 Patient Monitoring System: REF: PM100N, 10005941, DLPM100N, DL10005941, DSPM100N, 10005941-SG, DS10005941, 10005941J, 10005941JP, 10005941JPN
Product code: DQA Oximeter
Reason for recall: Bedside SpO2 Patient Monitoring System alarms not heard/recognized, resulting in: treatment delay, lack of low oxygen saturation response, respiratory failure, arrhythmia. Highlighting operator's manual: 1)For patient Safety don't silence/decrease alarm volume, 2)Sensor off alarm (no perfusion detected) is low priority alarm, 3)Set monitors to Homecare Mode outside of hospital/professional setting
Root cause tag: labeling and UDI
FDA root cause: Labeling design
Action: On 6/23/2025 correction notices were distributed to customers who where informed: Per Operator s Manual (http://manuals.medtronic.com): 1) Device alarm volume needs to be set to a level appropriate to be heard throughout the care environment at all times of day or night. Do not silence or decrease the volume of the audible alarm if patient safety could be compromised. 2) If the sensor comes off the patient, or no perfusion is detected, the device will notify 'sensor off' (low priority alarm) every 16 seconds and display a steady yellow visual indicator. If a low priority alarm immediately follows a higher priority alarm, a user may not recognize the higher priority clinical condition. 3) Monitors should be set to Standard Mode when in use in a hospital or hospital-type environment by trained medical personnel and set to Homecare Mode when a lay person will be using the monitor outside of a hospital or other professional care setting. With the monitor not in Homecare Mode, alarms could be silenced/muted and alarm limits altered In Clinical Facility Environments be sure the PM100N model is set to Standard Mode for general use and only set to Sleep Study Mode when conducting a sleep study. Device should be set to Homecare Mode prior to use. Firm's Technical Service at 800-255-6774 (option 1, then 2) can provide a four-digit password required to set a monitor to Homecare Mode. Provide the Home Use Guide to home caregivers. Clinicians should communicate the recall information to home use patients and caregivers. Pass on/post this notice for all those who need to be aware within your organization and to any organization where the product has been transferred/distributed. Complete and return the Customer Confirmation Form to [email protected] Firm will provide additional information when finalized. Questions - Contact firm's Customer Service at 800-962-9888, Option 2.
Quantity in commerce: 264,790
Distribution: Worldwide - US Nationwide distribution including in the states of MS, TX, FL, SC, VA, AZ, PA, MN, OH, CA, MI, CO, KS, IN, IL, TN, MO, IA, OK, WI, AK, NY, MD, AL, WV, GA, NC, AR, WA, SD, KY, DE, NJ, UT, NV, MA, MT, GU, NE, LA, HI, OR, RI, NH, ND, NM, ME, CT, DC, WY and the countries of Algeria, Andorra, Argentina, Australia, Austria, Bahamas, Bahrain, Bangladesh, Belgium, Bermuda, Bhutan, Bolivia, Bosnia And Herzegovina, Botswana, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Canary Islands, Chile, China, Colombia, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Egypt, Estonia, Finland, France, French Guiana, Germany, Ghana, Greece, Guadeloupe, Guatemala, Hong Kong, Hungary, India, Indonesia, Iran, Islamic Republic Of, Ireland, Isle of Man, Israel, Italy, Japan, Jordan, Kazakhstan, Kenya, Kuwait, Lebanon, Libya, Lithuania, Macedonia, Malaysia, Maldives, Malta, Mauritius, Mexico, Montenegro, Morocco, Myanmar, Namibia, Netherlands, New Zealand, North Macedonia, Norway, Oman, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Qatar, Reunion, Romania, Russia, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, South Korea, Spain, Sri Lanka, Sweden, Switzerland, Taiwan, Thailand, Tunisia, Turkey, Ukraine, United Arab Emirates, United Kingdom, Uruguay, Vietnam, Zimbabwe.
Product codes and lots: REF/UI-DI/Bundle Code/IFU Part Number: PM100N/10884521196728/NELL-HOMECARE, BNPULSOKSYMETR, PM100N, PM100NKIT, PM100NKITCHDE, PM100NKITCHFR, PM100NKITDA, PM100NKITDE-2, PM100NKITES, PM100NKITFI, PM100NKITFR, PM100NKIT-FR, PM100NKITIT, PM100NKIT-NL, PM100NKITNO, PM100NKITPT, PM100NKITSV, PM100NKITUK, PM100N-10, PM100N-2XMAXN, PM100N-2XMAXN-CC, PM100N-3DYS-CC, PM100N-DYS, PM100N-HC, PM100N-MAXN, PM100N-MAXN-CC, PM100N-OXIAN-CC/PT00156589 - AR - Arabic, PT00156609 - AR - Arabic, PT00156588 - BG - Bulgarian, PT00156610 - BG - Bulgarian, PT00156586 - CS - Czech, PT00156612 - CS - Czech, PT00156585 - DA - Danish, PT00156613 - DA - Danish, PT00156578 - DE - German, PT00156625 - DE - German, PT00156577 - EL - Greek, PT00156626 - EL - Greek, PT00156509 - EN - English, PT00156328 - EN - English, PT00156563 - ES - Spanish, PT00156639 - ES - Spanish, PT00156583 - ET - Estonian, PT00156615 - ET - Estonian, PT00156582 - FI - Finnish, PT00156616 - FI - Finnish, PT00156581 - FR - French, PT00156617 - FR - French, PT00156587 - HR - Croatian , PT00156611 - HR - Croatian , PT00156576 - HU - Hungarian, PT00156627 - HU - Hungarian, PT00156575 - IT - Italian, PT00156628 - IT - Italian, PT00156580 - KA - Georgian, PT00156618 - KA - Georgian, PT00156591 - KO - Korean, PT00156642 - KO - Korean, PT00156573 - LT - Lithuanian, PT00156630 - LT - Lithuanian, PT00156574 - LV - Latvian, PT00156629 - LV - Latvian, PT00156584 - NL - Dutch, PT00156614 - NL - Dutch, PT00156572 - NO - Norwegian, PT00156631 - NO - Norwegian, PT00156571 - PL - Polish, PT00156632 - PL - Polish, PT00156570 - PT-BR - Brazilian Portuguese, PT00156633 - PT-BR - Brazilian Portuguese, PT00156569 - RO - Romanian, PT00156634 - RO - Romanian, PT00156567 - RU - Russian, PT00156635 - RU - Russian, PT00156565 - SK - Slovak, PT00156637 - SK - Slovak, PT00156564 - SL - Slovenian, PT00156638 - SL - Slovenian, PT00156566 - SR - Serbian, PT00156636 - SR - Serbian, PT00156562 - SV Swedish, PT00156640 -SV - Swedish, PT00156561 - TR - Turkish, PT00156641 - TR - Turkish, PT00156590 - ZH - SimplifIed Chinese, PT00156643 - ZH - SimplifIed Chinese; 10005941/10884521163454/PM100N-10, PM100N-2XMAXN, PM100N-2XMAXN-CC, PM100N-3DYS-CC, PM100N-DYS, PM100N-HC, PM100N-MAXN, PM100N-MAXN-CC, PM100N-OXIAN-CC, BEDSIDESP2KIT2, NELLSPO2, PM100N-HC, NELL-HOMECARE, ROEBEDSIDEKIT, BEDSIDESP2PT2, BEDSIDESP2NO2, BEDSIDESP2PL2, BEDSIDESP2NL2, BEDSIDESP2KITNM, BEDSIDESP2K2UK, BEDSIDESP2K2IT, BEDSIDESP2K2FR, BEDSIDESP2K2-2, BEDSIDEKITISR/PT00156645 - AR - Arabic, PT00156647 - BG - Bulgarian, PT00156649 - CS - Czech, PT00156650 - DA - Danish, PT00156656 - DE - German, PT00156657 - EL - Greek, PT00156324 - EN - English, PT00156673 - ES - Spanish, PT00156652 - ET - Estonian, PT00156653 - FI - Finnish, PT00156654 - FR - French, PT00156648 - HR - Croatian, PT00156658 - HU - Hungarian, PT00156659 - IT - Italian, PT00156655 - KA - Georgian, PT00156677 - KO - Korean, PT00156661 - LT - Lithuanian, PT00156660 - LV - Latvian, PT00156651 - NL - Dutch, PT00156662 - NO - Norwegian, PT00156664 - PL - Polish, PT00156666 PT-BR - Brazilian Portuguese, PT00156667 - RO - Romanian, PT00156668 - RU - Russian, PT00156671 - SK - Slovak, PT00156672 - SL - Slovenian, PT00156669 - SR - Serbian, PT00156674 - SV - Swedish, PT00156675 - TR - Turkish, PT00156676 - ZH - Simplified Chinese, NELL-SPO2-AD3+ - Canadian, NELL-SPO2-AD3 - Canadian; 10005941/A8845211634501; DLPM100N/10884521527607; DL10005941/10884521173293; DSPM100N/DSPM100N; 10005941-SG/10884521171534/BNINHLLCODE, BNINNEL100A, BNINNEL100AS, BNINNEL100AVJ, BNINNEL100AYS, BNINNELDYS, BNHKLIBRANEOSET, BNHKLIBRASET; DS10005941/DS10005941; 10005941J/10005941JP; 10005941JP/884521512019; 10005941JPN/884521188689. All serial numbers

Enforcement reports

One row per recalled product line

FDA enforcement reports joined to recall event Z-2151-2025
Recall number	Class	Status	Voluntary or mandated	Report date	Classified
Z-2151-2025	Class II	Ongoing	Voluntary: Firm initiated	2025-07-30	2025-07-21

Product code DQA

MDM coverage of this record lists here, newest first.

About this record

Sourced from the FDA device recall database and the FDA enforcement reports, both ingested from openFDA. The recall record supplies the product, the reason and the product code; the enforcement report supplies the classification. The two datasets are exported by FDA on different days, and the date above is the older of the two, so nothing on this page is newer than it says.

MDM adds the root cause tag, derived from FDA’s own root cause text, and the cross-links to the product code, the clearances named on the record and MDM coverage. Where a recall has not been joined to an enforcement report, no classification is shown.

Data as of 2026-09-30, the FDA export date for this dataset. Page last changed 2026-09-05. View this recall on fda.gov (opens on fda.gov)