MAUDE MDR 5637653

MDR report key
5637653
Report number
3005011024-2016-00005
Event key
0
Event type
3
Date of event
2016-04-08
Date received
2016-05-06
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
SARAH BENNETT
Address
200 DEBUSK LANE POWELL TN 37849 US
Phone
865-865-8653
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1MANIFOLD KITANGIOGRAPHY/ANGIOPOLASTY KITDEROYAL INDUSTRIES, INC.OEQ77-40099040872031Y R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-05-060

Event Narratives#

N

Patient 1

INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT ((B)(4)) WAS RECEIVED INDICATING THAT A MANIFOLD KIT ((B)(4), LOT NUMBER 40872031) CONTAINED LOOSE CONNECTIONS THAT ALLOWED AIR TO ENTER THE SYSTEM. THE SAMPLE WAS RETURNED APRIL 25, 2016, TO DEROYAL AND FORWARDED TO THE MANUFACTURING FACILITY FOR EVALUATION AND AID IN DETERMINING THE ROOT CAUSE. THE MANUFACTURING FACILITY HAS FORWARDED IT TO DEROYAL'S PLASTICS GROUP FOR ADDITIONAL ANALYSIS. THE PLASTICS GROUP RECEIVED THE SAMPLE MAY 4. THE EVALUATION IS ONGOING AT THIS TIME. THE INVESTIGATION IS INCOMPLETE. WHEN NEW AND CRITICAL INFORMATION IS RECEIVED, THIS REPORT WILL BE UPDATED.

D

Patient 1

THE CUSTOMER IS EXPERIENCING QUALITY ISSUES WITH THE MANIFOLD KITS. THEY SAID SOME BATCHES ARE FINE BUT OTHERS HAVE VERY LOOSE 3 PORT MANIFOLDS AND STOPCOCKS. THEY HAVE HAD TO TIGHTEN THE 3 PORT MANIFOLD, WHICH BECOMES LOOSE IMMEDIATELY AFTER. THIS ALLOWS AIR TO BE INTRODUCED TO THE PROCEDURE, WHICH CAN BE EXTREMELY DANGEROUS. THIS ALSO CAUSES SALINE TO LEAK AND DELAYS IN PROCEDURES BECAUSE THEY HAVE TO SPEND TIME GETTING AIR BUBBLES OUT OF THE SYRINGE.

N

Patient 1

ROOT CAUSE: THE REPORTED ISSUE IS AN ISOLATED EVENT. EVALUATION OF THE RETURNED SAMPLE FAILED TO IDENTIFY A DISCREPANCY WITH THE MANIFOLD BUT CONFIRMED A LOOSE HANDLE ON RAW MATERIAL (B)(4) (STOPCOCK 1 WAY). THE LOOSE HANDLE COULD BE DUE TO AN ISSUE WITH HANDLING OR A VENDOR MANUFACTURING ERROR. CORRECTIVE ACTION: DUE TO THE INVESTIGATION AND ROOT CAUSE DETERMINATION, A CORRECTIVE ACTION HAS NOT BEEN TAKEN. INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT ((B)(4)) WAS RECEIVED INDICATING THAT A MANIFOLD KIT (FINISHED GOOD (B)(4), LOT NUMBER 40872031) CONTAINED LOOSE CONNECTIONS THAT ALLOWED AIR TO ENTER THE SYSTEM. THE SAMPLE WAS RETURNED APRIL 25, 2016, TO DEROYAL AND FORWARDED TO THE MANUFACTURING FACILITY FOR EVALUATION AND AID IN DETERMINING THE ROOT CAUSE. THE MANUFACTURING FACILITY HAS FORWARDED IT TO DEROYAL'S PLASTICS GROUP FOR ADDITIONAL ANALYSIS. THE PLASTICS GROUP RECEIVED THE SAMPLE MAY 4. THE MANIFOLD DID NOT LEAK DURING TESTING. HOWEVER, A LOOSE HANDLE WAS IDENTIFIED ON RAW MATERIAL (B)(4). RAW MATERIAL (B)(4) (STOPCOCK 1 WAY) IS SUPPLIED TO DEROYAL BY (B)(4). IT COULD NOT BE CONFIRMED IF THE LOOSE HANDLE IS DUE TO A VENDOR MANUFACTURING ISSUE OR A HANDLING ISSUE. DEROYAL HAS SOLD (B)(4) EACH OF THIS STOPCOCK COMPONENT FROM 2014 TO PRESENT. NO PREVIOUS ISSUES WERE IDENTIFIED AS OCCURRING FOR THIS RAW MATERIAL. THEREFORE, A SUPPLIER NOTIFICATION LETTER WAS ISSUED TO (B)(4). THE WORK ORDER WAS REVIEWED FOR DISCREPANCIES THAT MAY HAVE CONTRIBUTED TO THE REPORTED ISSUE. NO DISCREPANCIES WERE IDENTIFIED THAT COULD HAVE CONTRIBUTED TO THE REPORTED FAILURE. PREVENTIVE ACTION: DUE TO THE INVESTIGATION AND ROOT CAUSE DETERMINATION, A PREVENTIVE ACTION HAS NOT BEEN TAKEN. THE INVESTIGATION IS COMPLETE. IF NEW AND CRITICAL INFORMATION IS RECEIVED, THIS REPORT WILL BE UPDATED.

D

Patient 1

THE CUSTOMER IS EXPERIENCING QUALITY ISSUES WITH THE MANIFOLD KITS. THEY SAID SOME BATCHES ARE FINE BUT OTHERS HAVE VERY LOOSE 3 PORT MANIFOLDS AND STOPCOCKS. THEY HAVE HAD TO TIGHTEN THE 3 PORT MANIFOLD, WHICH BECOMES LOOSE IMMEDIATELY AFTER. THIS ALLOWS AIR TO BE INTRODUCED TO THE PROCEDURE, WHICH CAN BE EXTREMELY DANGEROUS. THIS ALSO CAUSES SALINE TO LEAK AND DELAYS IN PROCEDURES BECAUSE THEY HAVE TO SPEND TIME GETTING AIR BUBBLES OUT OF THE SYRINGE.