MAUDE MDR 6725921

MDR report key
6725921
Report number
3005011024-2017-00010
Event key
0
Event type
3
Date of event
2017-06-21
Date received
2017-07-19
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
1DIAGNOSTIC ANGIOGRAPHY PACKANGIOGRAPHY/ANGIOPLASTY KITDEROYAL INDUSTRIES, INC.OEQ89-744744720632R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12017-07-190

Event Narratives#

N

Patient 1

INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT WAS RECEIVED INDICATING THAT A 10 CC SYRINGE CONTAINED WITHIN DIAGNOSTIC ANGIOGRAPHY PACK (FINISHED GOOD (B)(4), LOT 44720632) CRACKED WHEN DRAWING BLOOD. THE DEFECTIVE SAMPLE WAS NOT AVAILABLE FOR RETURN. THE WORK ORDER FOR THE REPORTED LOT WAS REVIEWED FOR DISCREPANCIES THAT MAY HAVE CONTRIBUTED TO THE EVENT. NO DISCREPANCIES WERE IDENTIFIED. LOT MAPPING IDENTIFIED THE AFFECTED COMPONENT TO BE RAW MATERIAL (B)(4) -- A 10 CC SYRINGE SUPPLIED TO DEROYAL BY (B)(4). A SUPPLIER CORRECTIVE ACTION REQUEST (SCAR) HAS BEEN ISSUED TO (B)(4). AS OF THE DATE OF THIS REPORT, A RESPONSE HAS NOT BEEN RECEIVED. THE 2014-2016 SCAR AND SUPPLIER NOTIFICATION LETTER LOGS WERE REVIEWED FOR SIMILAR COMPLAINTS, AND SIMILAR COMPLAINTS WERE IDENTIFIED. THE INVESTIGATION IS ONGOING AT THIS TIME. WHEN NEW AND CRITICAL INFORMATION IS RECEIVED, THIS REPORT WILL BE UPDATED.

D

Patient 1

A 10 CC SYRINGE CRACKED WHILE THE STAFF WAS DRAWING BLOOD INTO THE SYRINGE. THE SYRINGE WAS A COMPONENT IN AN DIAGNOSTIC ANGIOGRAPHY KIT.