MAUDE MDR 6833556

MDR report key
6833556
Report number
3005011024-2017-00012
Event key
0
Event type
3
Date of event
2017-08-03
Date received
2017-08-31
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
2
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
1C-SECTION PACKKIT, SURGICAL INSTRUMENT, DISPOSABLEDEROYAL INDUSTRIES, INC.KDD89-863644274011R N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12017-08-310

Event Narratives#

N

Patient 1

INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT (B)(4) WAS RECEIVED INDICATING THAT A C-SECTION PACK (FINISHED GOOD 89-8636, LOT 44274011) CONTAINED A DRAPE WITH A PIECE OF PLASTIC ON IT. THE AFFECTED DRAPE WAS IDENTIFIED AS A C-SECTION DRAPE WITH POUCH AND FENESTRATION (B)(4). THE SAMPLE WAS INITIALLY REPORTED TO BE AVAILABLE FOR RETURN. HOWEVER, DUE TO THE CONTAMINATION OF THE SAMPLE, IT WAS NOT RETURNED FOR EVALUATION. INSTEAD, A PHOTOGRAPH OF THE REPORTED DEFECT WAS SENT. THE WORK ORDER FOR THE REPORTED LOT NUMBER WAS REVIEWED FOR DISCREPANCIES THAT MAY HAVE CONTRIBUTED TO THE REPORTED EVENT. NO DISCREPANCIES WERE IDENTIFIED. LOT MAPPING IDENTIFIED THE RAW MATERIAL DRAPE USED IN THE REPORTED FINISHED GOOD LOT WAS SUPPLIED TO DEROYAL BY (B)(4). THEREFORE, A SUPPLIER CORRECTIVE ACTION REQUEST (SCAR) WAS ISSUED AUGUST 10, 2017, TO (B)(4). THE PHOTOGRAPH OF THE REPORTED DEFECT ALSO WAS SENT TO THE SUPPLIER. THE SUPPLIER ACKNOWLEDGED RECEIPT OF THE SCAR ON AUGUST 16, 2017. A RESPONSE IS DUE SEPTEMBER 21, 2017. THE INVESTIGATION IS ONGOING AT THIS TIME. WHEN NEW AND CRITICAL INFORMATION IS RECEIVED, THIS REPORT WILL BE UPDATED.

D

Patient 1

A PIECE OF PLASTIC WAS FOUND ON A C-SECTION DRAPE WITH POUCH AND FENESTRATION DURING A PROCEDURE. THE PROCEDURE WAS DELAYED WHILE A NEW PACK WAS OPENED.