inforMED
MalfunctionJPK

COULTER® 4C® PLUS CELL CONTROL

Received Dec 31, 2010 · Event occurred Nov 21, 2010

Report 1061932-2010-00318 · MDR key 1943280

Device

Generic name

Hematology Quality Control Mixture

Model number

NA

Catalog number

7547114

Lot number

072300

Product problems

  • Fluid/Blood Leak

Patient

Not reported

  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

A CUSTOMER CONTACTED BECKMAN COULTER INC. (BCI) IN REGARDS TO A COULTER 4C PLUS CELL NORMAL CONTROL VIAL THAT LEAKED. THE VIAL LEAKED ON A TISSUE PAPER INSIDE THE REFRIGERATOR, AND NO OTHER AREAS WERE CONTAMINATED. THE CUSTOMER SUSPECTS THE CONTROL LEAKED OUT OF THE RUBBER CAP WHEN IT WAS INADVERTENTLY KNOCKED OVER SINCE IT HAD A LARGER THAN NORMAL PUNCTURE HOLE. AFTER EACH SPILL, THE CUSTOMER FOLLOWED THE LAB PROCEDURE TO CLEAN UP BIOHAZARD MATERIAL, WEARING PROPER PERSONAL PROTECTIVE EQUIPMENT. IT IS UNKNOWN IF MSDS WAS REVIEWED, BUT IT IS AVAILABLE. NO EXPOSURE TO MUCOUS MEMBRANES OR OPEN WOUNDS WAS REPORTED. NO ONE SOUGHT MEDICAL ATTENTION DUE TO THIS INCIDENT AND THERE WAS NO DEATH OR INJURY ATTRIBUTED TO THIS EVENT.

Additional Manufacturer Narrative

ACCORDING TO THE CUSTOMER'S QUALITY CONTROL FILE, THE VIAL HAD BEEN RUN 26 TIMES BEFORE THE LEAK. THE PRODUCT WAS RETURNED FOR ANALYSIS. A DEFINITIVE ROOT CAUSE FOR THIS EVENT HAS NOT BEEN DETERMINED.

Remedial action

  • Other