inforMED
MalfunctionCAP

PORTEX HYPERINFLATION RESUSCITATION MANOMETERS

Received Aug 4, 2021

Report 3012307300-2021-08062 · MDR key 12277180

Device

Generic name

Monitor, Airway Pressure (includes Gauge And/or Al

Manufacturer

St Paul

Model number

008201

Catalog number

008201

Lot number

4079320

Product problems

  • Product Quality Problem
  • Product Quality Problem

Patient

Unknown

  • Insufficient Information
  • No Clinical Signs, Symptoms or Conditions
  • Insufficient Information
  • No Clinical Signs, Symptoms or Conditions

Narrative

Description of Event or Problem

IT WAS REPORTED THAT THERE WERE INK STAINS ON THE SURFACE OF THE DEVICES.

Additional Manufacturer Narrative

OTHER, OTHER TEXT: THIS REMEDIATION MDR WAS GENERATED UNDER PROTOCOL (B)(4), AS A RESULT OF WARNING LETTER CMS#617147. NO PROBLEM OR ISSUES WERE IDENTIFIED DURING THE DEVICE HISTORY RECORD REVIEW. NO SAMPLES WERE RECEIVED BUT TWO PHOTOS WERE RECEIVED FOR EVALUATION. BASED ON THE IMAGES PROVIDED, IT WAS OBSERVED THAT THERE WERE INK STAINS INSIDE TUBE, THEREFORE FAILURE MODE CAN BE CONFIRMED. ROOT CAUSE CAN BE DETERMINED AS OPERATOR MISHANDLING USING PRODUCTION EQUIPMENT. A NOTIFICATION AWARENESS TO OPERATORS WERE ISSUED IN ORDER TO NOTIFY ALL PERSONNEL ABOUT ISSUE REPORTED WITH INK STAINS ON MANOMETER SURFACE, A QUALITY ALERT WAS IMPLEMENTED AT MANOMETER PRODUCTION LINE NOTIFYING ABOUT ISSUE REPORTED AND A POKA-YOKE IMPLEMENTATION IN FIXTURE AT MACHINE THAT WILL AVOID STARTING THE OPERATION WITHOUT ADDING A MANOMETER TUBE.