MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 01,08 report with the FDA on 2013-11-18 for SHUNT DENVER ASCITES PAK DOUBLE VALVE 42-2050 manufactured by Carefusion.
[15201384]
The distributor reported that during incoming inspection a black foreign particle was noted inside the tip of the tubing on one shunt.
Patient Sequence No: 1, Text Type: D, B5
[15601235]
(b)(4). In response to an fda inspection (conducted (b)(4) 2013), carefusion 2200 initiated a capa investigation (capa (b)(4)). As part of the capa, a retrospective review of the complaints for? Debris? And? Contamination? For applicable devices was conducted. It was determined that this report necessitates submission as a medical device report (mdr). Evaluation summary: evaluation of the sample, using 40x magnification, was able to confirm the presence of a small black particle on the distal end of the shunt catheter. The debris was measured to be less than 0. 08mm2 on the tappi standard. The shunt bodies are molded in a controlled manufacturing environment with strict controls on proper personal protective equipment. A device history review for the listed manufacturing lot showed (2) non-conformances. In each instance, the product was 100% culled and submitted to quality for inspection and release. There were no other recorded quality problems or rejections related to this incident. The manufacturing plant has also initiated a capa investigation ((b)(4)) to address the reported issue. All corrective and preventive actions (including manufacturing and quality plan improvements) will be implemented per the capa.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 1625685-2013-00074 |
| MDR Report Key | 3474776 |
| Report Source | 01,08 |
| Date Received | 2013-11-18 |
| Date of Report | 2010-05-19 |
| Date of Event | 2010-05-19 |
| Date Mfgr Received | 2010-07-14 |
| Date Added to Maude | 2014-02-25 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | JILL RITTORNO |
| Manufacturer Street | 75 NORTH FAIRWAY DRIVE |
| Manufacturer City | VERNON HILLS IL 60061 |
| Manufacturer Country | US |
| Manufacturer Postal | 60061 |
| Manufacturer Phone | 8473628056 |
| Manufacturer G1 | CAREFUSION 2200, INC |
| Manufacturer Street | 400 EAST FOSTER RD |
| Manufacturer City | MANNFORD OK 74044 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 74044 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | SHUNT DENVER ASCITES PAK DOUBLE VALVE |
| Generic Name | SHUNT, PERITONEAL |
| Product Code | KPM |
| Date Received | 2013-11-18 |
| Returned To Mfg | 2010-05-24 |
| Model Number | 42-2050 |
| Lot Number | L0C138 |
| Operator | PHYSICIAN |
| Device Availability | R |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | CAREFUSION |
| Manufacturer Address | 75 NORTH FAIRWAY DRIVE VERNON HILLS IL 60061 US 60061 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2013-11-18 |