inforMED
InjuryLSL

DX INSTRUMENTS

Received Oct 4, 2022 · Event occurred Jul 29, 2022

Report 2024800-2022-01094 · MDR key 15536163

Device

Generic name

Hologic Panther, Instrument System

Manufacturer

Hologic, Inc.

Model number

9120900000

Catalog number

902615

Product problems

  • Improper or Incorrect Procedure or Method
  • Improper or Incorrect Procedure or Method

Patient

Unknown

  • Eye Injury
  • Eye Injury

Narrative

Additional Manufacturer Narrative

HOLOGIC CONDUCTED INTERVIEWS WITH CUSTOMER AND INQUIRED IF OPERATOR WAS FOLLOWING RECOMMENDED PROTECTIVE REQUIREMENTS AS OUTLINED IN PANTHER SYSTEM OPERATOR MANUAL (AW-26055-001 - "MANUAL, OPERATOR'S, PANTHER/PANTHER FUSION 7.2, GLOBAL, IVD, ENGLISH, IVDR"). CUSTOMER CONFIRMED THAT THE OPERATOR WAS NOT WEARING PROTECTIVE EYEWEAR DURING INCIDENT. HOLOGIC WAS INFORMED THAT IMPACTED OPERATOR DID NOT SUFFER PERMANENT DAMAGE OR INJURY TO THE LEFT-EYE. OPERATOR IS CURRENTLY CLEARED FOR WORK AND HAS NO REDUCED VISION. A RED SPOT NEXT TO THE PUPIL IS HOWEVER STILL VISIBLE ON THE WHITE OF THE EYE HOWEVER OPERATOR IS CLAIMING SITUATION IS IMPROVING OVER TIME. FOLLOWING THE INCIDENT, HOLOGIC RESHARED A CUSTOMER TECHNICAL BULLETIN WITH CUSTOMER (CTB-00227_003_01 - "SYSTEM LIQUID WASTE COMPOSITION INFORMATION FOR THE PANTHER SYSTEM, PANTHER PLUS SYSTEM AND PANTHER FUSION SYSTEM") DETAILING THE COMPOSITION OF LIQUID WASTE. HOLOGIC FURTHER REEMPHASIZED THE IMPORTANCE OF ADHERING TO GENERAL GOOD LABORATORY PRACTICES AND STRESSED THE IMPORTANCE TO FOLLOW CORRECT OPERATING PROCEDURES WHEN HANDLING THE SYSTEM AND LIQUIDS AS OUTLINED IN THE INSTRUMENT OPERATOR MANUAL. HOLOGIC DEFINES THIS INCIDENT AS A USER ERROR. NO FURTHER INVESTIGATION OR EVENT MITIGATORY ACTIONS ARE REQUIRED AT THIS TIME.

Description of Event or Problem

DURING HOLOGIC SERVICE VISIT TO SITE ON (B)(6) 2022, CUSTOMER INFORMED HOLOGIC OF AN INJURY EVENT THAT HAPPENED ON (B)(6) 2022. HOLOGIC WAS NOT AWARE OF THE INCIDENT PRIOR TO SERVICE VISIT AS CUSTOMER DID NOT REPORT INJURY TO HOLOGIC. CUSTOMER RELAYED THAT DURING THE EMPTYING OF LIQUID WASTE OF PANTHER (SN (B)(4) INTO THE LABORATORY SINK, AN OPERATOR (FEMALE) RECEIVED A DROPLET/SPLASH OF LIQUID WASTE INTO HER LEFT EYE. OPERATOR IMMEDIATELY RINSED AFFECTED EYE WITH STERILE SALINE WATER EYE FLUSH SOLUTION AND CONTACTED A PHYSICIAN WITHIN 24 HOURS. MEDICAL DOCTOR DECIDED TO COMMENCE TREATMENT OF INJURY WITH ANTIBIOTICS, CORTISONE AND ANTI-INFLAMMATORY MEDICATION. HOLOGIC WAS INFORMED THAT AFFECTED OPERATOR IS STILL RECEIVING TREATMENT AT TIME OF EVENT REPORTING (B)(6) 2022). CUSTOMER ALSO STATED OPERATOR HAD VISITED PHYSICIAN 4 TIMES SINCE TIME OF INCIDENT. PHOTOGRAPHIC EVIDENCE OF THE INJURY WAS PROVIDED TO HOLOGIC ON WHICH A RED AREA NEXT TO THE PUPIL OF THE LEFT EYE IS OBSERVABLE. CUSTOMER IS RUNNING HBV, HCV AND HIV ASSAY ON PANTHER SYSTEM (B)(4).