MAUDE MDR 2711026

MDR report key
2711026
Report number
1721649-2012-00001
Event key
0
Event type
3
Date of event
2012-07-20
Date received
2012-08-16
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
STACEY HERRON
Address
582 MONROE ROAD SUITE 1424 SANFORD FL 32771 US
Phone
407-407-4077
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1SLIDEPREP PLUS CYTOLOGY CENTRIFUGESLIDEPREP PLUSSEPARATION TECHNOLOGY, INC. PART OF THERMO FISHER SCIENTIFICIFB100-400100-400033Y Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12012-08-160

Event Narratives#

D

Patient 1

CUSTOMER REPORTED THAT THE LID OF THE SLIDEPREP PLUS CYTOLOGY CENTRIFUGE WAS OPEN AND THE OPERATOR WAS PUTTING SLIDES INTO IT WHEN THE ROTOR BEGAN TO SPIN ON ITS OWN. THE OPERATOR NOTICED THE ROTOR BEGINNING TO SPIN AND PULLED HIS HAND AWAY BEFORE ANY INJURIES OCCURRED. THE CUSTOMER RETURNED THE DEVICE TO SEPARATION TECHNOLOGY, INC ON (B)(6) 2012 UNDER RGA 34447. INITIAL ATTEMPTS TO DUPLICATE THE FAILURE WERE UNSUCCESSFUL. CUSTOMER CONTACTED ON (B)(6) 2012, FOR MORE DETAILS REGARDING THE INCIDENT TO HELP WITH DUPLICATING THE FAILURE. CUSTOMER RESPONDED WITH AN E-MAIL ON (B)(6) 2012, THAT PROVIDED LITTLE ADDITIONAL DETAIL REGARDING THE INCIDENT OTHER THAN TO SAY THAT THE ROTOR DID NOT STOP TURNING WHEN THE STOP BUTTON WAS PRESSED, SO THE POWER SWITCH WAS TURNED TO OFF TO STOP THE ROTOR. ADDITIONAL ATTEMPTS TO CAUSE THE ROTOR TO TURN WITH THE LID OPEN WERE NOT SUCCESSFUL. ON (B)(6) 2012, THE DEVICE WAS OPENED TO INSPECT THE INSIDE. THE MOTOR GROUND WIRE, WHICH IS THE MOST LIKELY CAUSE OF THIS FAILURE, WAS TIGHT. NO OBVIOUS CAUSES TO THE FAILURE COULD BE FOUND. A JUMPER WIRE WAS FOUND TO BE PINCHED, BUT WITH NO METAL WIRE EXPOSED THROUGH THE INSULATION. A CONTINUITY TEST OF THE WIRE REVEALED NO ADVERSE EFFECT OF THE PINCHING. ON (B)(6) 2012, FURTHER INSPECTIONS WERE CONDUCTED BY AN ELECTRICAL ENGINEER. NO ABNORMALITIES COULD BE FOUND INSIDE THE DEVICE. THE ENGINEER TRIED WIGGLING AND VIBRATING KEY COMPONENTS OF THE DEVICE TO TRIGGER THE ROTOR MOTOR, WITH NO SUCCESS. THE ENGINEER CLOSED THE DEVICE AND BEGAN OPERATING IT AT VARIOUS SPEEDS, AND TRIED LOADING AND UNLOADING THE ROTOR TO TRIGGER THE MOTOR TO START, ALSO WITH NO SUCCESS. AS OF (B)(6) 2012, TESTING HAD STILL NOT BEEN ABLE TO DUPLICATE THE FAILURE. TESTING SHALL CONTINUE AND A FOLLOW-UP REPORT SHALL BE COMPLETED ONCE ALL POSSIBLE CAUSES ARE INVESTIGATED.