inforMED
MalfunctionDTG

MAGNET

Received Jan 30, 2024 · Event occurred Jan 2, 2024

Report 1000165971-2024-00080 · MDR key 18604568

Device

Generic name

Magnet, Test, Pacemaker

Model number

MAGNET

Catalog number

MAGNET

Lot number

M00008

Product problems

  • Packaging Problem
  • Packaging Problem

Patient

Unknown

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

Narrative

Additional Manufacturer Narrative

ANALYSIS SYNTHESIS: IT WAS REPORTED THAT ONE OF THE EXTERNAL LABELS ON TWO MAGNET PACKAGING BOXES WERE PLACED ON THE OPPOSITE SIDE TO THE USUAL ONE AND THAT THE MAGNETS WERE REVERSELY POSITIONED. REVIEW OF THE MANUFACTURING RECORDS ASSOCIATED TO THE PACKAGING OPERATION OF THE SUBJECT DEVICE REVEALED THAT THE DEVICE WAS PACKAGED AND RELEASED FOLLOWING ALL APPLICABLE PROCEDURES. THE REPORTED DIFFERENCES IN THE POSITION OF THE MAGNET AND THE EXTERNAL LABEL ARE MOST LIKELY DUE TO HUMAN ERROR. OPERATORS WILL BE RETRAINED TO REDUCE THE RECURRENCE OF THIS KIND OF ISSUE.

Description of Event or Problem

REPORTEDLY, THE POSITION OF ONE OF THE EXTERNAL LABEL IS DIFFERENTLY PLACED THAN USUAL AND THE MAGNET POSITION INSIDE THE BOX IS ALSO DIFFERENT.