ISPAN GAS TANK REGULATOR

Additional Manufacturer Narrative

INVESTIGATION INCLUDING ROOT CAUSE ANALYSIS IS IN PROGRESS. A SUPPLEMENTAL MDR WILL BE FILED AS NECESSARY IN ACCORDANCE WITH 21 CFR 803.56 WHEN ADDITIONAL REPORTABLE INFORMATION BECOMES AVAILABLE. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS: (B)(4).

Description of Event or Problem

A NURSE REPORTED THAT AN OPHTHALMIC GAS CYLINDER WAS NOT ALLOWING GAS TO COME. DETAILS OF PROCEDURE AND PATIENT HARM WAS NOT REPORTED. ADDITIONAL DETAILS HAD BEEN REQUESTED AND NONE RECEIVED TILL DATE. ADDITIONAL INFORMATION RECEIVED REPORTING THAT DURING SURGERY AN OPHTHALMIC GAS CYLINDER WAS NOT ALLOWING GAS TO COME. THERE WAS NO PATIENT HARM.

Additional Manufacturer Narrative

ADDITIONAL INFORMATION IS PROVIDED. THE PRODUCT UNDER INVESTIGATION IS NOT A SERVICEABLE DEVICE. THEREFORE, A SERVICE RECORD REVIEW WAS NOT PERFORMED. ONE REGULATOR WAS RETURNED FOR THIS INVESTIGATION. A NON-CONFORMANCE BASED REVIEW OF THE SERIAL NUMBER WAS PERFORMED AND DID NOT REVEAL ANY POTENTIAL CONTRIBUTING FACTORS TO THE REPORTED COMPLAINT. A MANUFACTURING DEVICE HISTORY RECORD (DHR) REVIEW WAS PERFORMED PRIOR TO PRODUCT RELEASE TO ENSURE THAT THE PRODUCT WAS MANUFACTURED IN COMPLIANCE WITH THE DEVICE MASTER RECORD. BASED ON THE ASSESSMENT, THE PRODUCT MET RELEASE CRITERIA. A CHECK OF THE BATCH PRODUCTION RECORD FOR THIS LOT SHOWED NO UNUSUAL MANUFACTURING ISSUES. A TOTAL OF 77 REGULATORS WERE RELEASED IN THIS LOT. A REVIEW FOR COMPLAINTS REPORTED AGAINST THIS LOT WAS PERFORMED. A POTENTIALLY RELEVANT COMPLAINT WAS FOUND (B)(4) AND REVIEWED AS PART OF THIS COMPLAINT. AIRGAS TEAM PERFORMED A CHECK OF CONFIRMED COMPLAINTS FOR REGULATORS WITH LOW OR NO FLOW SHOWED 39 COMPLAINTS SINCE THE BEGINNING OF 2017. ONE REGULATOR WAS RECEIVED IN GOOD CONDITION. THE REGULATOR WAS TESTED AND PASSED FOR FLOW WITH 3700 CC/MIN (SPECIFICATION IS 2000-4000 CC/MIN). HOWEVER, THE REGULATOR FAILED FOR DEAD END PRESSURE AT 320 POUNDS PER SQUARE INCH (PSI), IT WAS ALLOWING 10.50 PSI AND RISING TO FLOW THROUGH (SPECIFICATION IS <10 PSI). HOW OR WHY THE REGULATORS BECAME NONCONFORMING, IS INCONCLUSIVE BASED ON THE INFORMATION OBTAINED AT THIS TIME. BASED ON THE INFORMATION OBTAINED, THE ROOT CAUSE OF THE ISPAN REGULATOR NOT RELEASING GAS CAN BE ATTRIBUTED TO FAULTY REGULATORS. HOW OR WHY THE REGULATORS BECAME NONCONFORMING, IS INCONCLUSIVE BASED ON THE INFORMATION OBTAINED AT THIS TIME. MANUFACTURER WILL CONTINUE TO MONITOR DATA FOR EVIDENCE OF ADVERSE TRENDING AND TAKE FURTHER ACTION, AS APPROPRIATE. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS: (B)(4).