MalfunctionIFP
CARDINAL HEALTH
Received May 15, 2025 · Event occurred Apr 21, 2025
Report 22024631 · MDR key 22024631
Device
Product problems
- Device label look-alike
Patient
NA · Unknown
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Description of Event or Problem
10% FORMALIN WAS DELIVERED TO THE PROCEDURAL AREA AND REPROCESSING LOCATIONS INSTEAD OF 70% ISOPROPYL ALCOHOL. BOTH CONTAINERS (10% FORMALIN AND 70% ISOPROPYL ALCOHOL) HAVE SIMILAR APPEARANCE. THE 10% FORMALIN WAS INADVERTENTLY USED WHEN ADDING FLUID TO THE 70% ISOPROPYL ALCOHOL CONTAINER, RESULTING IN ENDOSCOPES BEING REPROCESSED WITH THE INCORRECT FLUID. WE RECOMMEND CHANGING THE JUGS TO MAKE THEM MORE DISTINGUISHABLE.