inforMED
MalfunctionMLR

V-PRO MAX 2 STERILIZER

Received Dec 28, 2023 · Event occurred Dec 1, 2023

Report 3005899764-2023-00071 · MDR key 18409138

Device

Generic name

Sterilizer

Model number

MAX 2

Catalog number

VP50003101

Product problems

  • Use of Device Problem
  • Use of Device Problem

Patient

NA · Unknown

  • Burn(s)
  • Burn(s)

Narrative

Additional Manufacturer Narrative

A STERIS SERVICE TECHNICIAN ARRIVED ONSITE FOLLOWING THE REPORTED EVENT TO INSPECT THE STERILIZER AND FOUND THE UNIT TO BE OPERATING PROPERLY. NO ISSUES WITH THE FUNCTION OR OPERATION OF THE STERILIZER WERE IDENTIFIED, AND THE STERILIZER WAS RETURNED TO SERVICE. THE V-PRO MAX 2 STERILIZER OPERATOR MANUAL STATES (6-16), "STERIS RECOMMENDS (IN ACCORDANCE WITH ANSI/AAMI GUIDELINES) WEARING CHEMICAL-RESISTANT GLOVES WHEN USING THE STERILIZATION UNIT." THE OPERATOR MANUAL FURTHER STATES (1-2), "DANGER - CHEMICAL INJURY HAZARD: ANY VISIBLE LIQUIDS IN THE CHAMBER OR ON THE LOAD MUST BE TREATED AS CONCENTRATED HYDROGEN PEROXIDE. OBSERVE ALL HYDROGEN PEROXIDE HANDLING PRECAUTIONS. WHEN HANDLING HYDROGEN PEROXIDE, WEAR APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT." ADDITIONALLY, USER FACILITY PERSONNEL SHOULD ENSURE ALL INSTRUMENTS ARE PROPERLY DRY PRIOR TO PLACEMENT IN THE V-PRO MAX 2 STERILIZER. THE V-PRO MAX 2 STERILIZER OPERATOR MANUAL, (A-1) STATES, "DRY ALL ITEMS THOROUGHLY. ENSURE ALL MOISTURE IS REMOVED FROM ALL INTERNAL PARTS (INCLUDING LUMENS). IF NOT, RESIDUAL HYDROGEN PEROXIDE MAY REMAIN AT CYCLE COMPLETION AND/OR A CYCLE ABORT OCCURS. ONLY DRY ITEMS ARE TO BE PLACED IN STERILIZATION UNIT." IN-SERVICE TRAINING WILL BE OFFERED ON THE IMPORTANCE OF WEARING PROPER PPE, SPECIFICALLY GLOVES, WHILE OPERATING THEIR VPRO MAX 2 STERILIZERS. A FOLLOW-UP MDR WILL BE SUBMITTED WHEN ADDITIONAL INFORMATION BECOMES AVAILABLE.

Description of Event or Problem

THE USER FACILITY REPORTED VIA PMDA REPORT THAT AN EMPLOYEE OBTAINED A BURN ON THEIR FINGER WHEN HANDLING A POUCH AFTER IT WAS PROCESSED IN THEIR V-PRO MAX 2 STERILIZER. THE EMPLOYEE WASHED THEIR HANDS AND RETURNED TO WORK. NO REPORT OF PROCEDURE DELAY.

Additional Manufacturer Narrative

THE TECHNICIAN COUNSELED USER FACILITY PERSONNEL ON THE IMPORTANCE OF WEARING PROPER PPE, SPECIFICALLY GLOVES, WHILE OPERATING THEIR V-PRO MAX 2 STERILIZER. NO ADDITIONAL ISSUES HAVE BEEN REPORTED.