SITUATE
Received May 18, 2022 · Event occurred Apr 11, 2022
Report 1717344-2022-00600 · MDR key 14429409
Device
Generic name
Counter, Sponge, Surgical
Manufacturer
Covidien Mfg Dc BoulderModel number
01-0034Catalog number
01-0034
Product problems
- False Positive Result
- False Positive Result
Patient
21 YR · Female
- Unintended Radiation Exposure
- Unintended Radiation Exposure
Narrative
Description of Event or Problem
ACCORDING TO THE REPORTER, AFTER VAGINAL DELIVERY, THE DEVICE HAD A SCAN ERROR MESSAGE. ALL COUNTS WERE CORRECT/ALL RAYTEC'S VISUALIZED. SCANNED PATIENT LOW ABD/SUPRAPUBLIC WHICH INDICATED A RETAINED SPONGE. REPEATED SCAN WITH SAME RESULTS. ATTEMPTED SCAN WITH ANOTHER MACHINES WITH SAME RESULTS. ENSURED CORD WAS NOT ON OR AROUND PATIENT WHILE SCANNING. FINALLY DOCUMENTED THE CONFIRMATION NUMBER IN PATIENT CHART WITH THE LAST SCAN. DELIVERY TABLE MOVED AWAY FROM PATIENT. VISUAL CHECK UNDER AND AROUND PATIENT. CHECKED ALL OPEN RAYTECS ON DELIVERY TABLE FOR RFID DETECTION DEVISE. NONE WERE MISSING. THE DOCTOR REQUESTED TO RE-EXAMINE THE PATIENT. THEY DID A VAGINAL EXAM AND NOTHING WAS FOUND. RECOUNTED RAYTEC ON DELIVERY TABLE AND COUNTS WERE AGAIN CORRECT. ORDERED PORTABLE PELVIC X-RAY, WHICH WAS NEGATIVE. AFTER X-RAY RESULTS, FINALLY BROKE DOWN THE TABLE WITH SPONGES. EVERYTHING WAS EXPLAINED TO THE PATIENT INCLUDING THE MD TO SHOW THE PATIENT THE SPONGES. BOTH MACHINES WERE USED EARLIER IN THE SHIFT AND DID NOT DETECT ANYTHING. MACHINES ARE CURRENTLY IN THE OFFICE, SO THEY ARE NOT USED UNTIL EXAMINED BY BIOMED OR MEDTRONIC REPRESENTATIVE. THERE WAS NO PATIENT INJURY.
Additional Manufacturer Narrative
IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.
Additional Manufacturer Narrative
D10 CONCOMITANT PRODUCT: 01-0035 SITUATE (SERIAL NUMBER: (B)(6)), 01-0035 SITUATE (SERIAL NUMBER: (B)(6)) ADDITIONAL INFORMATION: D19, D10, G1, G3, H3, H6 H3 EVALUATION SUMMARY: MEDTRONIC CONDUCTED AN INVESTIGATION BASED UPON ALL INFORMATION RECEIVED. THE DEVICE WAS AVAILABLE FOR EVALUATION. THE EVALUATION FOUND NO POTENTIALLY CONTRIBUTING FACTORS, AND THE SAMPLE MET ALL RELATED SPECIFICATIONS. IT WAS REPORTED THAT THE DEVICE GAVE A FALSE POSITIVE DETECTION. THE REPORTED ISSUE COULD NOT BE CONFIRMED. THE MOST LIKELY CAUSE COULD NOT BE IDENTIFIED BECAUSE NO RELATED PROBLEM WAS DETECTED WITH THE DEVICE. THE MANUFACTURING RECORDS FOR EACH DEVICE ARE THOROUGHLY REVIEWED PRIOR TO RELEASE TO ENSURE THAT IT MEETS ALL MEDTRONIC QUALITY SPECIFICATIONS. MEDTRONIC IS SUBMITTING THIS REPORT TO COMPLY WITH FDA REPORTING REGULATIONS UNDER 21 CFR PARTS 4 AND 803. THIS REPORT IS BASED UPON INFORMATION OBTAINED BY MEDTRONIC, WHICH THE COMPANY MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE FDA. MEDTRONIC HAS MADE REASONABLE EFFORTS TO OBTAIN MORE COMPLETE INFORMATION AND HAS PROVIDED AS MUCH RELEVANT INFORMATION AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE OF THIS REPORT. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY FDA, MEDTRONIC, OR ITS EMPLOYEES THAT THE DEVICE, MEDTRONIC, OR ITS EMPLOYEE CAUSED OR CONTRIBUTED TO THE EVENT DESCRIBED IN THE REPORT. IN PARTICULAR, THIS REPORT DOES NOT CONSTITUTE AN ADMISSION BY ANYONE THAT THE PRODUCT DESCRIBED IN THIS REPORT HAS ANY ¿DEFECTS¿ OR HAS ¿MALFUNCTIONED¿. THESE WORDS ARE INCLUDED IN THE FDA 3500A FORM AND ARE FIXED ITEMS FOR SELECTION CREATED BY THE FDA TO CATEGORIZE THE TYPE OF EVENT SOLELY FOR THE PURPOSE OF REGULATORY REPORTING. MEDTRONIC OBJECTS TO THE USE OF THESE WORDS AND OTHERS LIKE THEM BECAUSE OF THE LACK OF DEFINITION AND THE CONNOTATIONS IMPLIED BY THESE TERMS. THIS STATEMENT SHOULD BE INCLUDED WITH ANY INFORMATION OR REPORT DISCLOSED TO THE PUBLIC UNDER THE FREEDOM OF INFORMATION ACT. ANY REQUIRED FIELDS THAT ARE UNPOPULATED ARE BLANK BECAUSE THE INFORMATION IS CURRENTLY UNKNOWN OR UNAVAILABLE. A GOOD FAITH EFFORT WILL BE MADE TO OBTAIN THE APPLICABLE INFORMATION RELEVANT TO THE REPORT. IF INFORMATION IS PROVIDED IN THE FUTURE, A SUPPLEMENTAL REPORT WILL BE ISSUED.