inforMED
MalfunctionDSA

AMC

Received May 24, 2024 · Event occurred Apr 4, 2024

Report 1063285-2024-00001 · MDR key 19397580

Device

Generic name

3 Lead Disposable Din To Pinch, Shld, 50", Om Combiner, Aha

Model number

LWM-329DS50/3A

Catalog number

LWM-329DS50/3A

Lot number

CC231113B

Product problems

  • Defective Device
  • Defective Device

Patient

NA · Unknown

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

Narrative

Description of Event or Problem

IT WAS REPORTED BY CUSTOMER THAT : LEAD BROKE APART AT THE PINCH CLIP CONNECTOR WITH ONE HALF COMPLETELY COMING OFF RESULTING WITH BRIEF LOSS OF MONITORING MID MEDICAL PROCEDURE AND SKIN INTEGRITY RISK AS THE BROKEN PIECE WAS LOOKED/FELT FOR UNDER THE PATIENT BUT NOT LOCATED UNTIL POST PROCEDURE WHEN THEY COULD BE MOVED. THIS MEANS A HARD PLASTIC PIECE AND ATTACHED METAL SPRING WAS UNDER THE PATIENT FOR APPROXIMATELY 30 MINUTES. NO INJURY OR ADDITIONAL MEDICAL INTERVENTION REPORTED.

Additional Manufacturer Narrative

PRODUCT WAS INSPECTED AT THE AMC LOCATION AND DEFECTIVE PRODUCT WAS INSPECTED. BREAKAGE WAS CONFIRMED, HOWEVER IT WAS NOT IDENTIFIED A POTENTIAL CAUSE. DEFECTIVE PARTS WERE SENT TO THE SUPPLIER FOR FURTHER INVESTIGATION. SUPPLIER CONDUCTED AN INVESTIGATION THROUGH THEIR MANUFACTURING PROCESS AND DID NOT IDENTIFY ANY ISSUE THAT COULD CAUSE THE DEFECT. SUPPLIER IS PARTNERING WITH PINCH COMPONENT SUPPLIER TO UNDERSTAND THEIR PROCESSS AND TO IDENTIFY ANY POTENTIAL CAUSE. FINAL DETAILED INVESTIGATION WILL BE SUBMITTED IN ANOTHER FOLLOW-UP REPORT. IN ADDITION, UNSUCESSFUL ATTEMPTS HAVE BEEN MADE TO OBTAIN MORE DETAILS OF THE REPORTED EVENT. AMC WILL CONTINUE TO FOLLOW-UP AND WILL UPDATE REPORT ACCORDINGLY.

Description of Event or Problem

IT WAS REPORTED BY CUSTOMER THAT : LEAD BROKE APART AT THE PINCH CLIP CONNECTOR WITH ONE HALF COMPLETELY COMING OFF RESULTING WITH BRIEF LOSS OF MONITORING MID MEDICAL PROCEDURE AND SKIN INTEGRITY RISK AS THE BROKEN PIECE WAS LOOKED/FELT FOR UNDER THE PATIENT BUT NOT LOCATED UNTIL POST PROCEDURE WHEN THEY COULD BE MOVED. THIS MEANS A HARD PLASTIC PIECE AND ATTACHED METAL SPRING WAS UNDER THE PATIENT FOR APPROXIMATELY 30 MINUTES. NO INJURY OR ADDITIONAL MEDICAL INTERVENTION REPORTED.

Additional Manufacturer Narrative

INVESTIGATION RESULTS: LOTS AVAILABLE AT THE FACILITY FOR LWM-329DS50/3A WERE PLACED ON QUARANTINE WHILE INVESTIGATION TOOK PLACE. COMPLAINT REVIEWED WAS PERFORMED ((B)(6) 2023 TO (B)(6) 2024), AND NO ADDITIONAL COMPLAINTS RELATED TO THE DEFECT WERE IDENTIFIED FOR THIS PART NUMBER. ONE (1) COMPLAINT FROM 2023 WAS IDENTIFIED FOR A SIMILAR PART NUMBER WITH A SIMILAR DEFECT. THE MANUFACTURING DATE WAS APPROXIMATELY ONE (1) YEAR PRIOR TO THE SUBJECT DEFECT. NO TREND IDENTIFIED. THE PRODUCT WAS RECEIVED AT THE FACILITY AND INSPECTED. IN PERFORMING A VISUAL INSPECTION ON ONE (1) 3 LEAD DISPOSABLE DIN TO SHLD, THE RA AND LA LEADS SUSTAINED SOME DAMAGE ON THE PINCH CLIPS (2820001) AND (2820003), CONFIRMING THE COMPLAINT. THE ONE (1) SAMPLE LEAD WIRE WAS SENT TO THE SUPPLIER FOR EVALUATION MAY 09, 2024. ADDITIONAL SAMPLES OF THE PRODUCT BOUNDED WERE SENT AS WELL. SUPPLIER COMPLETED MANUFACTURING INVESTIGATION ON MAY 8TH, 2024. SUPPLIER DID NOT IDENTIFY ANY AREAS THAT COULD CAUSE BREAKAGE TO THE PINCH BODY DURING THEIR PRODUCTION ASSEMBLY PROCESS. IN ADDITION, SUPPLIER EVALUATED SAMPLES UPON ARRIVAL AT THEIR FACILITY AND NO CAUSE FOR THE DEFECT WAS IDENTIFIED. BASED ON THE DHR REVIEWED, OF LOT CC231113B, SUPPLIER IDENTIFIED THAT THE RAW MATERIAL LOT NUMBER WAS 2013110417. SUPPLIER CONDUCTED AN INVESTIGATION WITH RAW MATERIAL SUPPLIER AND NO ANOMALIES WERE IDENTIFIED IN THE PROCESS CONSISTENT WITH THE DEFECT. ADDITIONAL ATTEMPTS WERE MADE TO OBTAIN MORE INFORMATION FROM THE CUSTOMER, HOWEVER ADDITIONAL INFORMATION WAS NOT RECEIVED. AMC/LIFESYNC WILL CONTINUE TO MONITOR FOR THE DEFECT AND WILL RE-OPEN INVESTIGATION IF ADDITIONAL INFORMATION IS RECEIVED AFTER COMPLAINT CLOSURE.

Description of Event or Problem

IT WAS REPORTED BY CUSTOMER THAT : LEAD BROKE APART AT THE PINCH CLIP CONNECTOR WITH ONE HALF COMPLETELY COMING OFF RESULTING WITH BRIEF LOSS OF MONITORING MID MEDICAL PROCEDURE AND SKIN INTEGRITY RISK AS THE BROKEN PIECE WAS LOOKED/FELT FOR UNDER THE PATIENT BUT NOT LOCATED UNTIL POST PROCEDURE WHEN THEY COULD BE MOVED. THIS MEANS A HARD PLASTIC PIECE AND ATTACHED METAL SPRING WAS UNDER THE PATIENT FOR APPROXIMATELY 30 MINUTES. NO INJURY OR ADDITIONAL MEDICAL INTERVENTION REPORTED.