inforMED
DeathFCE

ENEMA ADM UNIT -BAG /SOAP/PAD

Received May 18, 2010 · Event occurred Mar 16, 2010

Report 1423507-2010-00027 · MDR key 1702431

Device

Generic name

Enema Adm Unit -bag /soap/pad

Manufacturer

Cardinal Health

Model number

6010G

Catalog number

6010G

Lot number

0100545

Product problems

  • Defective Component

Patient

79 YR

  • Death
  • Extravasation
  • Bowel Perforation

Narrative

Additional Manufacturer Narrative

NO SAMPLE WAS RECEIVED FOR EVAL; THEREFORE, WE ARE UNABLE TO CONFIRM THE ISSUE REPORTED. THE PVC TUBING IS DESIGNED AND VALIDATED FOR PT USE. THE CURRENT RIGIDITY OF PVC TUBING AND SHAPE, FACILITATES THE ENEMA ADMINISTRATION UNDER SUPERVISION OF MEDICAL STAFF. THE DEVICE MASTER RECORD AND DEVICE HISTORY RECORDS FOR THE LOTS REPORTED INDICATE THAT THE COMPLETE MFG PROCESSES AND INSPECTIONS SHOWED NO ISSUES. THE EQUIPMENT, PROCESSES AND PARTS USED IN THE MFR OF THIS PRODUCT WERE VERIFIED AND CONFORM TO THE PRODUCT SPECIFICATIONS. BASED ON THE INFO THAT HAS BEEN REVIEWED THERE IS NO INDICATION OF ANY PRODUCT FAILURE, THEREFORE, NO CORRECTIVE ACTION WILL BE TAKEN AT THIS TIME.

Description of Event or Problem

RECTAL PERFORATION FOLLOWED WITH LIQUID EXTRAVASATION PERITONEAL OF THE PT. PROBE TIP COULD HAVE BEEN DEFECTIVE CAUSING THE PERFORATION.