inforMED
MalfunctionMPO

NOVAPLUS INFANT HEEL WARMER SQUEEZE

Received May 2, 2023 · Event occurred Jan 1, 1980

Report 1423537-2023-00926 · MDR key 16854166

Device

Generic name

Infant Heel Warmer (chemical Heat Pack)

Manufacturer

Mo016 Mo-moberly

Model number

V11460-010

Catalog number

V11460-010

Lot number

UNKNOWN

Product problems

  • Burst Container or Vessel
  • Burst Container or Vessel

Patient

65 YR · Male

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

Narrative

Description of Event or Problem

CUSTOMER REPORTED THAT WHEN STAFF TRIED TO ACTIVATE THE HEAL WARMER FOR A PATIENT, THE HEAL WARMER BURST. IT'S REPORTED THAT IT WAS ALREADY UNDER PRESSURE FROM IT ALREADY BEING ACTIVATED WHICH CAUSED THE HEAL WARMER TO BURST. THERE WAS NO INJURY OR ADVERSE EFFECT CAUSED BY THE HOT PACK.

Additional Manufacturer Narrative

AT THE TIME OF THIS INVESTIGATION, THE DEVICE HISTORY RECORD COULD NOT BE VERIFIED AS A LOT NUMBER WAS NOT PROVIDED. A SAMPLE WAS NOT RETURNED FOR EVALUATION; THEREFORE, A ROOT CAUSE COULD NOT BE DETERMINED. WE WILL CONTINUE TO MONITOR COMPLAINT TRENDS AND UTILIZE THE INFORMATION AS PART OF CONTINUOUS IMPROVEMENT.