inforMED
MalfunctionMPO

INFANT HEEL WARMER SQUEEZE 4X4IN

Received Aug 3, 2023 · Event occurred Jun 30, 2023

Report 1423537-2023-00974 · MDR key 17454208

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

57 YR · Female

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

Narrative

Description of Event or Problem

IT HAS BEEN REPORTED THAT A LABORATORY SUPPORT TECHNICIAN WAS ACTIVATING THE HEEL WARMER BY SQUEEZING IT, THE TOP OF THE HEEL WARMER BUSTED OPEN. THERE WAS NO INJURY/ADVERSE EVENT. THE PACK MATERIAL GOT ON THE CLINICIAN'S CLOTHES. THERE WAS NO SKIN CONTACT. IT WAS WASHED AWAY WITH SOAP AND WATER. THE CLINICIAN WAS NOT HARMED.

Additional Manufacturer Narrative

TWO SAMPLES WERE RECEIVED FOR EVALUATION AND WERE VISUALLY INSPECTED FOR ANY DEFECTS. THE SAMPLES WERE ALREADY ACTIVATED AND A TEAR WAS NOTED IN POUCH. THE ROOT CAUSE WHICH CONTRIBUTED TO THE TEAR WAS DUE TO A MACHINE MISALIGNMENT. THE DEVICE HISTORY RECORD OF THE COMPLAINT LOT WAS REVIEWED. THE LOT WAS INSPECTED AND RELEASED IN COMPLIANCE WITH ALL REQUIREMENTS. NO ANOMALIES WERE FOUND DURING REVIEW OF THE RECORDS. CARDINAL HEALTH WILL CONTINUE TO MONITOR AND TREND ALL SIMILAR REPORTED PRODUCT RELATED ISSUES.