inforMED
MalfunctionMPO

INFANT HEEL WARMER,SQUEEZE, 4X4IN

Received Aug 26, 2022 · Event occurred Jul 21, 2022

Report 1423537-2022-00829 · MDR key 15301841

Device

Generic name

Infant Heel Warmer (chemical Heat Pack)

Model number

11460-010T

Catalog number

11460-010T

Lot number

UNKNOWN

Product problems

  • Burst Container or Vessel
  • Burst Container or Vessel

Patient

Female

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

Narrative

Description of Event or Problem

CUSTOMER REPORTED A HEEL WARMER WAS OBTAINED TO PERFORM A HEEL STICK. UPON SQUEEZING THE SIDES OF THE HEEL WARMER, PER INSTRUCTION, THE LIQUID EXPLODED OUT THE TOP. THE LIQUID LANDED ON THE LAB TECH. ACCORDING TO THE WITNESS STATEMENT, "THE HEEL WARMER "EXPLODED ALL OVER" THE EMPLOYEE. PER HER SUPERVISOR, THE PACK MATERIAL HIT HER NECK AND SCRUB TOP. SHE CHANGED HER CLOTHES, AND NO INJURY WAS REPORTED. NO DEMOGRAPHIC INFORMATION PROVIDED.

Additional Manufacturer Narrative

REVIEW OF THE DEVICE HISTORY REPORT WAS COMPLETED ON THE REPORTED LOT NUMBER, V2C227. THE LOT WAS FOUND TO HAVE BEEN MANUFACTURED ON 3/23/22 AND RELEASED TO PREDETERMINED SPECIFICATIONS. MAINTENANCE RECORDS WERE ALSO REVIEWED. NO ANOMALIES WERE FOUND DURING REVIEW OF THE RECORDS. NO PHYSICAL SAMPLES WERE RETURNED DUE TO WHICH A ROOT CAUSE COULD NOT BE DETERMINED. SAMPLE PHOTOS WERE REVIEWED, BUT WE ARE STILL NOT ABLE TO DETERMINE A ROOT CAUSE BASED ON EVALUATION OF PHOTOS. CARDINAL HEALTH WILL CONTINUE TO MONITOR COMPLAINT TRENDS FOR THIS ISSUE.