SOUTHMEDIC NON-STERILE DISPOSABLE SAFETY SCALPEL

Additional Manufacturer Narrative

THE MANUFACTURER RECEIVED NOTIFICATION OF THIS INCIDENT ON APRIL 15, 2021. PER THE CUSTOMER, THE SAFETY SCALPEL, AS PART OF AN UMBILICAL VESSEL CATHETER (UVC) TRAY, WOULD NOT OPEN AS IT WAS IN THE LOCKED POSITION, WHICH DELAYED UVC PLACEMENT. THE CUSTOMER COULD NOT CONFIRM IF THE SCALPEL WAS RECEIVED IN THE LOCKED POSITION OR IF LOCKING OCCURRED IN THE EMERGENCY ROOM. THIS INCIDENT WAS ALSO REPORTED BY THE KIT MANUFACTURER (3009211636-2020-00727). THE SAFETY SCALPEL ASSOCIATED WITH THE INCIDENT IS SOLD IN BULK TO THE KIT MANUFACTURER FOR FURTHER PACKAGING INTO PROCEDURE KITS. QUALITY CONTROL CHECKS ARE UTILIZED BY THE SAFETY SCALPEL MANUFACTURER TO ENSURE SCALPELS ARE NOT PROVIDED IN A LOCKED POSITION. THE INCIDENT WAS LIKELY DUE TO USER ERROR DUE TO MISUNDERSTANDING OF HOW THE SAFETY SCALPEL OPENS, CLOSES AND LOCKS. ALTERNATIVE SCALPEL BRANDS MAY HAVE SHEATHS THAT ARE FULLY REMOVED TO EXPOSE THE BLADE. THE MANUFACTURER SAFETY SCALPELS RETRACT TO EXPOSE THE BLADE, MAY BE CLOSED FOR SAFE PASSING AND CAN BE LOCKED FOR SAFE DISPOSAL.

Description of Event or Problem

THE CUSTOMER REPORTED THAT IN AN EMERGENCY SITUATION THE SCALPEL IN THE UMBILICAL VESSEL CATHETER (UVC) SET APPEARED LOCKED AND WAS UNABLE TO BE OPENED BY THE PROVIDERS DURING A NEONATAL CODE SITUATION. ADDITIONAL INFORMATION PROVIDED BY THE CUSTOMER STATED THAT THERE WAS LESS THAN A MINUTE OF A DELAY IN INSERTING THE UVC LINE DURING AN ADVANCED RESUSCITATION IN A C-SECTION. ADDITIONAL INFORMATION PROVIDED BY THE CUSTOMER STATED THAT THEY COULD NOT PULL THE SCALPEL'S SAFETY SHEATH DOWN, STATING THAT IT WAS "LOCKED IN". THE CUSTOMER STATED THAT SINCE THE INCIDENT OCCURRED IN AN EMERGENCY SITUATION AND DOES NOT KNOW IF THE SCALPEL WAS ALREADY IN THE LOCKED POSITION WHEN REMOVED FROM THE UVC KIT. THE CUSTOMER STATED THAT THEY USED A DIFFERENT SCALPEL THAT THEY GOT FROM THE OR TABLE AS A REPLACEMENT TO PLACE THE LINE. THE NEWBORN EXPIRED. THE CUSTOMER WOULD NOT ANSWER IF THEY BELIEVED THAT THE ISSUE WITH THE DEVICE CAUSED OR CONTRIBUTED TO THE PATIENT'S DEATH.