inforMED
MalfunctionGAZ

VISCOUS FLUID CONTROL TUBING SET (SILICONE OIL INJ/EXT)

Received Jul 23, 2024 · Event occurred Jul 2, 2024

Report 1644019-2024-01654 · MDR key 19811928

Device

Generic name

Tubing, Noninvasive

Model number

NA

Catalog number

8065750957

Lot number

169WPY

Product problems

  • Disconnection
  • Disconnection

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

A REVIEW OF THE DEVICE HISTORY RECORD TRACEABLE TO THE REPORTED LOT NUMBER INDICATES THAT THE PRODUCT WAS PROCESSED AND RELEASED ACCORDING TO THE PRODUCT ACCEPTANCE CRITERIA. THE RETURNED SAMPLE WAS VISUALLY INSPECTED AD NO OBVIOUS DEFECTS WERE CONFIRMED. THE GRAY PLUNGER WAS FOUND AT THE BOTTOM OF THE SYRINGE BARREL. SILICONE OIL WAS OBSERVED ON THE CANNULAS. A CONSOLE, REPRESENTING CURRENT SOFTWARE VERSIONS WAS USED TO TEST THE TUBING. THE SYRINGE WAS CONNECTED TO THE ADAPTER AND COULD FULLY ENGAGE. THE SYRINGE SEATED IN THE ADAPTER AND THE CANNULA¿S SEATED ON THE SYRINGE LUER LOCK BARB FIRMLY AND SECURELY. THE LED (LIGHT-EMITTING DIODE) RINGS ON THE CONSOLE TURNED GREEN AS THE GRAY CONNECTOR WAS ENGAGED TO THE CONSOLE INDICATING THE PROPER COMMUNICATION BETWEEN THE CONNECTOR AND THE CONSOLE. THE CANNULA DID NOT POP OFF DURING FUNCTIONAL TESTING. PRESSURE WAS STABLE DURING FUNCTIONAL TESTING. THE PLUNGER IN THE SYRINGE MOVED SMOOTHLY DURING OPERATION. THE ROOT CAUSE OF THE CUSTOMER COMPLAINT COULD NOT BE ESTABLISHED SINCE THE RETURNED SAMPLE MET SPECIFICATIONS, ALL CONNECTIONS WERE FOUND TO FIT SECURELY. NO CONTRIBUTING FACTORS COULD BE IDENTIFIED THAT COULD CAUSE THE REPORTED COMPLAINT. AFTER THE INVESTIGATION OF THIS COMPLAINT, IT HAS BEEN DETERMINED THAT THIS SAMPLE MET SPECIFICATIONS. THEREFORE, NO ACTION WILL BE TAKEN AT THIS TIME. NO ADVERSE TRENDS HAVE BEEN OBSERVED ASSOCIATED WITH THE REPORTED PRODUCT AND EVENT. QUALITY ASSURANCE WILL CONTINUE TO MONITOR CUSTOMER COMPLAINTS VIA THE COMPLAINT REVIEW MEETINGS, AND WILL TAKE ACTION FOR ANY FUTURE OCCURRENCES AS IS DEEMED NECESSARY. THE MANUFACTURER INTERNAL REFERENCE NUMBER IS: (B)(4).

Description of Event or Problem

THE NURSE REPORTED THAT TUBING WAS NOT TIGHTLY SEALED AND AIR WAS LEAKING, WHICH LED TO THE INABILITY TO PERFORM THE SURGERY NORMALLY AFTER COMPLETING THE PRELIMINARY SURGERY FOR LEFT RETINAL DETACHMENT SURGERY. THE ENTIRE SURGERY WAS POSTPONED FOR TEN MINUTES BUT COMPLETED ON THE SAME DAY. THE PROCEDURE TYPE WAS UNKNOWN. THERE WAS NO PATIENT HARM.

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).