MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a user facility report with the FDA on 2016-06-01 for PAIN TRAY 89-8611 manufactured by Deroyal Industries, Inc..
[46268587]
Investigation summary: an internal complaint ((b)(4)) was received regarding 5cc and 3cc syringes in finished good 89-8611 (pain tray). When filled, small black foreign objects could be seen floating in the syringes, which were intended to be used for injection. A sample was returned for evaluation and received may 9. An evaluation of the sample confirmed the reported issue. The syringes ((b)(4)) are supplied to deroyal by (b)(4). Therefore, a supplier corrective action request has been sent to (b)(4). The investigation is ongoing at this time. When new and critical information is received, this report will be updated.
Patient Sequence No: 1, Text Type: N, H10
[46268588]
The 5cc and 3cc syringes in the pack are filled with medication for injection, and on multiple occasions, there have been very small black foreign objects floating in the syringes. The doctor was unable to use the syringe when this happens, and a new one is pulled to complete the procedure.
Patient Sequence No: 1, Text Type: D, B5
[50736034]
Root cause: the syringes within the convenience kit are supplied to deroyal by (b)(4) therefore, a supplier corrective action request (scar) was issued to (b)(4). In its response, (b)(4) stated the male mold compresses the vulcanized rubber sheet into the female mold to form the piston tip. Another machine then punches each piston tip out of the sheet. During this punch process, loose rubber particles can be created. Corrective action: in its scar response, the supplier stated the plunger manufacturer has a mechanical shaking process to dislodge any particulate present and then water wash steps to remove these particulates. There is also additional incoming in-process inspection and final inspection processes to control the issue. Investigation summary: an internal complaint (b)(4) was received regarding 5cc and 3cc syringes in finished good 89-8611 (pain tray). When filled, small black foreign objects could be seen floating in the syringes, which were intended to be used for injection. A sample was returned for evaluation and received may 9. An evaluation of the sample confirmed the reported issue. The syringes (raw materials 5-20058 and 5-20060) are supplied to deroyal by (b)(4). A scar was issued to (b)(4) and a response has been received. In its response, the supplier indicated inventory was statistically sampled and no issues were found. The visual inspection sampling process has been increased for the requested issue. The work order for the finished good was reviewed for discrepancies that would have contributed to the reported issue. No discrepancies were identified. Deroyal will continue to monitor post-market feedback and will recognize in the future if the issue reoccurs after the implemented actions. Preventive action: in its scar response, (b)(4) stated a preventive action has not been taken. The investigation is complete at this time. If new and critical information is received, this report will be updated.
Patient Sequence No: 1, Text Type: N, H10
[50736035]
The 5cc and 3cc syringes in the pack are filled with medication for injection, and on multiple occasions, there have been very small black foreign objects floating in the syringes. The doctor was unable to use the syringe when this happens, and a new one is pulled to complete the procedure.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3005011024-2016-00007 |
| MDR Report Key | 5690890 |
| Report Source | USER FACILITY |
| Date Received | 2016-06-01 |
| Date of Report | 2016-07-26 |
| Date of Event | 2016-04-18 |
| Date Mfgr Received | 2016-05-02 |
| Date Added to Maude | 2016-06-01 |
| 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 | 3 |
| Event Location | 3 |
| Manufacturer Contact | SARAH BENNETT |
| Manufacturer Street | 200 DEBUSK LANE |
| Manufacturer City | POWELL TN 37849 |
| Manufacturer Country | US |
| Manufacturer Postal | 37849 |
| Manufacturer Phone | 8653626112 |
| Manufacturer G1 | DEROYAL INDUSTRIES, INC. |
| Manufacturer Street | 1501 EAST CENTRAL AVENUE |
| Manufacturer City | LAFOLLETTE TN 37766 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 37766 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | PAIN TRAY |
| Generic Name | NERVE BLOCK TRAY (KIT) |
| Product Code | OGJ |
| Date Received | 2016-06-01 |
| Returned To Mfg | 2016-05-09 |
| Catalog Number | 89-8611 |
| Lot Number | 41809957 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | DEROYAL INDUSTRIES, INC. |
| Manufacturer Address | 1501 EAST CENTRAL AVENUE LAFOLLETTE TN 37766 US 37766 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2016-06-01 |