MAUDE MDR 6445677

MDR report key
6445677
Report number
1121308-2017-00005
Event key
0
Event type
3
Date received
2017-03-30
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
USER SONIA IRIZARRY
Address
311 ENTERPRISE DRIVE PLAINSBORO NJ 08536 US
Phone
609-609-6099
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1IDRT-TS (INTL) SINGLE 4X5IDRT-TSINTEGRA LIFESCIENCES CORPORATIONMDD84051105NKA352492Y R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12017-03-300

Event Narratives#

N

Patient 1

INTEGRA HAS COMPLETED THEIR INTERNAL INVESTIGATION ON MARCH 27, 2017. THE INVESTIGATION INCLUDED: METHODS: REVIEW OF DEVICE HISTORY RECORDS. REVIEW OF COMPLAINTS HISTORY. RESULTS: THE FAILURE IS UNCONFIRMED. NO FAILURE ANALYSIS COULD BE PERFORMED AS THE PRODUCT WAS USED ON THE PATIENT DURING SURGERY, AND HAS NOT RETURNED. DHR REVIEW; THE NC/EVENT LOG AND BATCH RECORD WERE REVIEWED FOR ANY EVENTS RELATED TO THE LOTS OF THE COMPONENTS USED TO MANUFACTURE THE PRODUCT. ANY EVENTS OR NCS RELATED TO THE PARENT DISPERSION LOT OR THE REPORTED FINISHED GOODS LOT OF ANY TIME PERIOD WAS CONSIDERED. NO EVENTS OR NCS WERE FOUND FOR THIS LOT OR IT?S COMPONENT LOTS RELATED TO SKIN VISUAL APPEARANCE DEFECTS. COMPLAINTS HISTORY; A QUERY OF THE COMPLAINT DATABASE FOR THE TIMEFRAME OF 12 MONTHS ((B)(6) 2016-(B)(6) 2017) WAS PERFORMED USING THE INDIVIDUAL KEYWORDS: ?SKIN? AND ?THICK? OR ?THIN? OR ?UNEVEN?. NO OTHER COMPLAINTS WERE FOUND. CONCLUSION: THE ROOT CAUSE IS LIKELY USER MISINTERPRETATION OF THE REQUIRED THICKNESS RANGE FOR IDRT. BASED ON THE COMPLAINT BACKGROUND PROVIDED, REVIEW OF THE BATCH PRODUCTION RECORDS AND TRENDING, RISK ANALYSIS, AND THE COMPLAINT TYPE, IT CAN BE DETERMINED THAT THE DOCTOR NOTICED A VISUAL DIFFERENCE IN THE THICKNESS OF BOTH IDRT SHEETS WHEN COMPARED, BUT BASED ON THE MANUFACTURING PROCESS OF THE COMPLAINT LOT, NO FAILURE OCCURRED. COMPANY SOP DEFINES UNEVEN OR DESCENDING THICKNESS OF SPONGE FROM END TO END > 2:1 RATIO AS A DEFECT. MANUFACTURING PERFORMS 100% VISUAL INSPECTION OF ALL SPONGES PER SOP TO ENSURE EACH DEVICE MEETS THIS CRITERION. IF AN OUT OF SPECIFICATION THICKNESS WAS IDENTIFIED WITH ANY DEVICE DURING INSPECTION, THE IMPACTED DEVICE WOULD BE REJECTED. THICKNESS DOES INHERENTLY VARY FOR THE COATED SKIN PRODUCTS, BUT THE THICKNESS OF BOTH THE UNCOATED PRODUCT AND SILICONE IS CHECKED/DOCUMENTED IN PROCESS AND WAS WITHIN THE ACCEPTABLE RANGE. PRODUCTS ARE ONLY RELEASED BASED ON FINISHED GOODS RELEASE TESTING AND BATCH RECORD CRITERIA.

D

Patient 1

2 OF 2 REPORTS - OTHER MFG REPORT NUMBER: 1121308-2017-00004. IT WAS REPORTED A THICKNESS ISSUE ON TWO IDRT LAYERS: ONE IS THICKER THAN AND THE OTHER IS THINNER THAN USUAL. THE CUSTOMER WAS NOT ABLE TO CONFIRM WHICH DEVICE OF THE TWO WAS THICKER OR THINNER, BUT WHEN THE CUSTOMER COMPARED THE TWO DEVICES THEY WERE BOTH VISUALLY DIFFERENT IN THICKNESS. NO PATIENT INJURY REPORTED AND THE EVENT DID NOT LEAD TO SURGICAL DELAY.