14100_90

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,health report with the FDA on 2017-04-17 for 14100_90 manufactured by Advanced Sterilization Products.

Event Text Entries

[73028036] The correct brand name is sterrad? Chemical indicator strip. The correct catalog number is 14100. The dhr was reviewed and the involved lot met manufacturer specifications at the time of release. No anomalies were observed that would contribute to the customer's experienced issue.
Patient Sequence No: 1, Text Type: N, H10


[73028037] A customer reported a sterrad? Chemical indicator strip did not change color correctly after a completed sterrad? Nx cycle. The affected load was recalled. There was no report of infection, injury or harm to patient(s) associated with this issue. Although there is no report of patient injury or harm and no prior incidents have resulted in serious injury, advanced sterilization products (asp) has determined in this situation sterility cannot be assured. Therefore, as a matter of policy asp had decided to report all incidents of sterrad? Chemical indicator strips not changing color correctly.
Patient Sequence No: 1, Text Type: D, B5


[96243341] Asp investigation summary: the investigation included a review of the device history record (dhr), trending analysis by lot number, visual analysis, retains analysis, concomitant product evaluation, and system risk analysis (sra). The dhr was reviewed and all process specifications were met before the release of the product. Trending analysis by lot number was reviewed from 09/24/2016 to 03/23/2017 and trending was not exceeded. Visual analysis was not performed as the product was not returned for evaluation. Retains testing was not performed since user error was determined to be the cause. The concomitant sterrad? Nx was tested by an asp field service engineer (fse). Upon arrival, the fse confirmed the customer was using aesculap pans which are known to absorb h2o2 as they age and was advised to switch to aptimax trays instead. The issue has since resolved. The sra indicates the risk associated with a quality problem with no impact on safety is "low. " the assignable cause of the issue can be attributed to using aged aesculap trays. The fse provided customer education regarding the trays and the issue has since been resolved. The issue will continue to be tracked and trended.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number2084725-2017-00193
MDR Report Key6498840
Report SourceCOMPANY REPRESENTATIVE,HEALTH
Date Received2017-04-17
Date of Report2017-03-23
Date of Event2017-01-15
Date Mfgr Received2017-06-15
Device Manufacturer Date2016-09-01
Date Added to Maude2017-04-17
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactJOAQUIN KURZ
Manufacturer CityIRVINE CA 92618
Manufacturer CountryUS
Manufacturer Postal92618
Manufacturer Phone9497893837
Manufacturer G1ADVANCED STERILIZATION PRODUCTS
Manufacturer Street33 TECHNOLOGY DRIVE
Manufacturer CityIRVINE CA 92618
Manufacturer CountryUS
Manufacturer Postal Code92618
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Generic NameCHEMICAL STERILIZATION PROCESS INDICATOR
Product CodeJOJ
Date Received2017-04-17
Catalog Number14100_90
Lot Number251611-02
ID Number14100-90
Device Expiration Date2018-03-31
OperatorHEALTH PROFESSIONAL
Device AvailabilityN
Device AgeDA
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerADVANCED STERILIZATION PRODUCTS
Manufacturer Address33 TECHNOLOGY DRIVE IRVINE CA 92618 US 92618


Patients

Patient NumberTreatmentOutcomeDate
10 2017-04-17

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