inforMED
MalfunctionCAP

PORTEX DISPOSABLE MANOMETER

Received Feb 15, 2022

Report 3012307300-2022-03434 · MDR key 13537500

Device

Generic name

Monitor, Airway Pressure

Manufacturer

St Paul

Model number

008201

Catalog number

008201

Lot number

4089533

Product problems

  • Product Quality Problem
  • Product Quality Problem

Patient

Unknown

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

Narrative

Additional Manufacturer Narrative

MULTIPLE PHOTOGRAPHS OF THE MANOMETER WERE PROVIDED IN SUPPORT OF THE INVESTIGATION. IT WAS CONFIRMED THAT THERE WERE INK STAINS PRESENT ON THE OUTSIDE OF THE MANOMETER. WHICH ARE NOT IN ACCORDANCE WITH MANUFACTURER SPECIFICATIONS. THE ROOT CAUSE OF THE REPORTED EVENT WAS DETERMINED TO BE RELATED TO THE MISHANDLING OF THE DEVICE DURING THE MANUFACTURING PROCESS, RESULTING IN INK STAINS ON THE OUTSIDE OF THE MANOMETER. TO ADDRESS THE ISSUE, A NOTIFICATION WAS PROVIDED TO ALL MANUFACTURING OPERATORS TO NOTIFY REGARDING THIS ISSUE, AND A (B)(6) IMPLEMENTATION IN THE MACHINE FIXTURE TO PREVENT THE ISSUE FROM OCCURRING. A DHR REVIEW WAS PERFORMED SUBSEQUENT TO THE MANUFACTURING OF THE DEVICE AND PRIOR TO ITS RELEASE. NO PROBLEMS OR ISSUES WERE IDENTIFIED DURING THIS DHR REVIEW.

Description of Event or Problem

IT WAS REPORTED THAT THERE ARE INK STAINS ON THE SURFACE OF THE NANOMETER. THERE WAS NO PATIENT INVOLVEMENT REPORTED.