inforMED
MalfunctionLWH

SC+ QBL SOFTWARE

Received Dec 3, 2024 · Event occurred Nov 19, 2024

Report 3015967359-2024-02376 · MDR key 20837736

Device

Generic name

Counter, Sponge, Surgical

Catalog number

0894-000-005

Product problems

  • High Readings
  • High Readings

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

D4: ADDITIONAL INFORMATION IS NOT AVAILABLE TO COMPLETE THE GTIN, THE SERIAL NUMBER IS UNKNOWN.

Description of Event or Problem

DURING A PROCEDURE, THE CUSTOMER COUNTED OUT FIVE 4X18-LAP SPONGES. USING THE AUTOMATED SPONGE WEIGHING TAB, THE CUSTOMER PLACED THE FIVE LAPS INTO THE BUCKET AND TAPPED ¿ANALYZE.¿ THE USER RECEIVED A MESSAGE SAYING THAT THE DRY WEIGHT EXCEEDED THE WET WEIGHT, EVEN THOUGH SEVERAL OF THE LAPS WERE SOAKED IN BLOOD. THE AUTOMATED SPONGE COUNT/WEIGHT PORTION DOUBLED THE DRY WEIGHT OF THE SPONGES. THE PROCEDURE WAS COMPLETED SUCCESSFULLY WITH THE SAME DEVICE WITHOUT A SURGICAL DELAY; NO MEDICAL INTERVENTION OR ADVERSE CONSEQUENCES WERE REPORTED.

Description of Event or Problem

DURING A PROCEDURE, THE CUSTOMER COUNTED OUT FIVE 4X18-LAP SPONGES. USING THE AUTOMATED SPONGE WEIGHING TAB, THE CUSTOMER PLACED THE FIVE LAPS INTO THE BUCKET AND TAPPED ¿ANALYZE.¿ THE USER RECEIVED A MESSAGE SAYING THAT THE DRY WEIGHT EXCEEDED THE WET WEIGHT, EVEN THOUGH SEVERAL OF THE LAPS WERE SOAKED IN BLOOD. THE AUTOMATED SPONGE COUNT/WEIGHT PORTION DOUBLED THE DRY WEIGHT OF THE SPONGES. THE PROCEDURE WAS COMPLETED SUCCESSFULLY WITH THE SAME DEVICE WITHOUT A SURGICAL DELAY; NO MEDICAL INTERVENTION OR ADVERSE CONSEQUENCES WERE REPORTED.

Additional Manufacturer Narrative

CORRECTED DATA: UPON FURTHER INVESTIGATION, THE SPECIFIC CAUSE OF THE INACCURATE MEASUREMENT WILL NOT RESULT IN HARM GREATER THAN SEVERITY 0 (USER ANNOYANCE), AND THEREFORE IT IS NOT LIKELY THAT A REOCCURRENCE OF THIS EVENT WILL LEAD TO A SERIOUS INJURY OR DEATH.