THIS PRODUCT IS A 500ML BOTTLE OF AGAR THAT IS MELTED THEN POURED INTO PLATES OR TUBES. THE TECHNOLOGISTS IN THE LAB WERE USING A MICROWAVE TO MELT THE FIVE BOTTLES OF MEDIA RATHER THAN A WATER BATH. THE BOTTLES EXPLODED IN THE MICROWAVE AND THREE TECHS GOT HURT. ONE OR MORE OF THE FOLLOWING TREATMENTS WERE PROVIDED TO THE INDIVIDUALS INVOLVED IN THIS INCIDENT: X-RAYS, STITCHES, BANDAGE TO COVER WOUNDS, ANTIBIOTICS AND TYLENOL. NO ADDITIONAL SPECIFIC TREATMENT INFORMATION WAS PROVIDED.
N
Patient 1
THIS INCIDENT IS THE SAME EVENT REFERENCED IN MDR REPORT #1119779-2010-00004. THERE WERE TWO DIFFERENT PRODUCTS IN THE MICROWAVE WHEN THIS INCIDENT OCCURRED. BOTH MEDIA ARE LABELED "FOR LAB USE ONLY". THIS CUSTOMER IS AN INDUSTRIAL TESTING LABORATORY THAT MELTS THE AGAR IN ORDER FOR FORM PLATES/TUBES OF MEDIA TO USE IN SPECIMEN TESTING. THE CUSTOMER ALSO FOLLOWS USP GUIDELINES. THE FOLLOWING IS AN EXCERPT FROM GENERAL INFORMATION (NON-MANDATORY) USP CHAPTER 1117 GOOD LABORATORY PRACTICES REGARDING THE REMELTING OF MEDIA: "REMELTING OF AN ORIGINAL CONTAINER OF SOLID MEDIA SHOULD BE PERFORMED ONLY ONCE TO AVOID MEDIA WHOSE QUALITY IS COMPROMISED BY OVERHEATING OR POTENTIAL CONTAMINATION. IT IS RECOMMENDED THAT REMELTING BE PERFORMED IN A HEATED WATER BATH OR BY USING FREE-FLOWING STEAM. THE USE OF MICROWAVE OVENS AND HEATING PLATES IS COMMON, BUT CARE SHOULD BE TAKEN TO AVOID DAMAGING MEDIA BY OVERHEATING AND TO AVOID THE POTENTIAL INJURY TO LABORATORY PERSONNEL FROM GLASS BREAKAGE AND BURNS. THE MOLTEN AGAR MEDIUM SHOULD BE HELD IN A MONITORED WATER BATH AT A TEMPERATURE OF 45 TO 50 FOR NOT MORE THAN 8 HOURS." ALTHOUGH USP ACKNOWLEDGES THE USE OF A MICROWAVE, BD DOES NOT RECOMMEND THIS. THE FOLLOWING EXCERPT FOR HANDLING THIS TYPE OF MEDIA APPEARS IN THE (B)(4) MANUAL, MANUAL OF MICROBIOLOGICAL CULTURE MEDIA: "NOTE: USE OF A MICROWAVE OVEN TO MELT TUBED OR BOTTLED MEDIA IS NOT RECOMMENDED." NO CORRECTIVE ACTIONS ARE PLANNED AT THIS TIME.