inforMED
MalfunctionMPO

INFANT HEEL WARMER SQUEEZE 4X4IN

Received Jul 25, 2023 · Event occurred Jun 29, 2023

Report 1423537-2023-00969 · MDR key 17393895

Device

Generic name

Infant Heel Warmer (chemical Heat Pack)

Manufacturer

Mo016 Mo-moberly

Model number

11460-010T

Catalog number

11460-010T

Lot number

V3D237

Product problems

  • Burst Container or Vessel
  • Burst Container or Vessel

Patient

Unknown

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

Narrative

Description of Event or Problem

CUSTOMER REPORTED, STAFF MEMBER SQUEEZED NEWBORN HEEL WARMER TO ACTIVATE AND THE GEL LEAKED OUT. IMMEDIATELY UPON SQUEEZING, THE PRODUCT PACKAGING SEPARATED ALONG AN EDGE CAUSING A HOLE AND INNER CONTENTS TO LEAK OUT. CUSTOMER FEARS STAFF OR PATIENT COULD BE HURT FROM WARMER LEAKING OUT. NO INJURY TO PATIENT OR STAFF FOR THIS INCIDENT.

Additional Manufacturer Narrative

THE COMPLAINT WAS FORWARDED TO THE MANUFACTURING FACILITY WHERE IT IS CURRENTLY STILL UNDER INVESTIGATION. A FOLLOW-UP REPORT WILL BE FILED ONCE THE RESULTS HAVE BEEN COMPLETED.

Additional Manufacturer Narrative

ONE SAMPLE WAS RECEIVED FOR EVALUATION. THE SAMPLE WAS ALREADY ACTIVATED; THEREFORE, THE ROOT CAUSE COULD NOT BE CONFIRMED. DEVICE HISTORY RECORD REVIEW WAS COMPLETED ON THE REPORTED LOT V3D237, AND THE LOT WAS MANUFACTURED AND RELEASED IN COMPLIANCE WITH ALL REQUIREMENTS. CARDINAL HEALTH HAS MADE A BUSINESS DECISION TO CLOSE THE SITE WHICH MANUFACTURES PRODUCT 11460-010T AND TRANSITION TO A THIRD-PARTY MANUFACTURER.