inforMED
MalfunctionPWY

SAFE-T PLUS LUMBAR PUNCTURE TRAY ADULT

Received Nov 10, 2023 · Event occurred Oct 16, 2023

Report 1625685-2023-00109 · MDR key 18111131

Device

Generic name

Lumbar Puncture Tray (adult & Pediatric)

Manufacturer

Carefusion, Inc

Catalog number

4301CSP

Lot number

UNKNOWN

Product problems

  • Contamination
  • Contamination

Patient

Unknown

  • Insufficient Information
  • Insufficient Information

Narrative

Description of Event or Problem

IT WAS REPORTED BY THE CUSTOMER THAT TUBE/VILE #1 PROVIDED IN THIS LUMBAR PUNCTURE KIT HAD A FOREIGN BODY (FB) IN IT. INITIALLY, CUSTOMER THOUGHT IT WAS JUST THE WAY THE TUBES LOOK DUE TO LIGHT REFLECTING. THEN AS CSF BEGAN TO COLLECT THE FOREIGN BODY BEGAN TO FLOAT AND APPEARS AS A BLACK SPECK OF DEBRIS. THE FB THEN SINKS AND CAN BE SEEN AT THE VERY BOTTOM OF THE TUBE. CENTRAL PROCESSING WAS MADE AWARE AND A SPECIMEN NOTE WAS ENTERED IN NOTING THE PRESENCE OF THE FOREIGN BODY AND THAT THIS TUBE SHOULD BE STORED/KEPT AND NOT UTILIZED FOR TESTING UNLESS ABSOLUTELY NECESSARY. VERBATIM: RCC RECEIVED A COMPLAINT VIA EMAIL. EMAIL(S) ATTACHED. TUBE/VILE #1 PROVIDED IN THIS LUMBAR PUNCTURE KIT HAD A FOREIGN BODY (FB) IN IT. INITIALLY, I THOUGHT IT WAS JUST THE WAY THE TUBES LOOK DUE TO LIGHT REFLECTING. THEN AS CSF BEGAN TO COLLECT THE FB BEGAN TO FLOAT AND APPEARS AS A BLACK SPECK OF DEBRIS. THE FB THEN SINKS AND CAN BE SEEN AT THE VERY BOTTOM OF THE TUBE. CENTRAL PROCESSING WAS MADE AWARE AND A SPECIMEN NOTE WAS ENTERED IN NOTING THE PRESENCE OF THE FOREIGN BODY AND THAT THIS TUBE SHOULD BE STORED/KEPT AND NOT UTILIZED FOR TESTING UNLESS ABSOLUTELY NECESSARY.

Additional Manufacturer Narrative

(B)(4). INITIAL EMDR SUBMISSION. DEVICE PROBLEM CODE: A1801. PATIENT PROBLEM CODE: F24. NO PHOTOS OR PHYSICAL SAMPLES THAT DISPLAY THE REPORTED CONDITION WERE AVAILABLE FOR INVESTIGATION. A DEVICE HISTORY REVIEW COULD NOT BE COMPLETED AS NO BATCH NUMBER WAS PROVIDED. BASED ON THE AVAILABLE INFORMATION WE ARE NOT ABLE TO IDENTIFY A ROOT CAUSE AT THIS TIME. SHOULD YOU EXPERIENCE ANY PROBLEMS WITH OUR PRODUCT, EXAMINATION OF THE PRODUCT INVOLVED MAY PROVIDE CLARIFICATION AS TO THE CAUSE FOR THE REPORTED FAILURE. COMPLAINTS RECEIVED FOR THIS DEVICE AND REPORTED CONDITION WILL CONTINUE TO BE TRACKED AND TRENDED. OUR QUALITY TEAM REGULARLY REVIEWS THE COLLECTED DATA FOR IDENTIFICATION OF EMERGING TRENDS. BASED ON NO SAMPLE, THE INVESTIGATION CONCLUDED, BD WAS NOT ABLE TO VERIFY THE INDICATED FAILURE. H3 OTHER TEXT : SEE MANUFACTURE NARRATION.