TEMPLE TOUCH PRO MCU UNIT, NON-INVASIVE CORE TEMP MONT
Received Aug 20, 2025 · Event occurred Aug 14, 2025
Report 1043214-2025-00003 · MDR key 22852952
Device
Product problems
- Unintended Movement
- Unintended Movement
Patient
NA · Unknown
- Burn(s)
- Rash
- Skin Inflammation/ Irritation
- Burn(s)
- Rash
- Skin Inflammation/ Irritation
Narrative
Additional Manufacturer Narrative
A USER FACILITY REPORTED, THE TEAMS PLACED THE TTP IN PREOP ON THE PATIENT'S FOREHEAD AND WHAT I CAN TELL FROM THE CHARTING, THE CRNA DID USE THE TTP (THERMOREGULATION BAND OPTION SELECTED *TEMPORAL) TO CAPTURE INTRAOP TEMPS AS WELL. IN PACU, THE TTP HAD BECOME DISLODGED AND WAS NOT GIVING CORRECT TEMPERATURES, SO THE PACU NURSE REMOVED THE TTP SENSOR TO REPOSITION IT TO RE-PLACE IT ON THE PATIENT'S FOREHEAD AREA AND NOTICED THAT THERE WERE 4 SMALL DARK SQUARES ON THE PATIENTS SKIN THAT ALIGNED WITH THE SENSORS ON THE TTP." DEROYAL INDUSTRIES, INC. REQUESTED RETURN OF THE DEVICE, BUT IT HAS NOT YET BEEN RECEIVED. A SUPPLIER CORRECTIVE ACTION REQUEST (SCAR) WILL BE ISSUED TO THE SUPPLIER, MEDISIM, LTD. THIS INVESTIGATION IS NOT COMPLETE AT THIS TIME. NO FURTHER INFORMATION IS AVAILABLE AT THIS TIME. WE WILL PROVIDE FOLLOW UP REPORT WHEN ADDITIONAL INFORMATION BECOMES AVAILABLE.
Description of Event or Problem
A USER FACILITY REPORTED, "THE TEAMS PLACED THE TTP IN PREOP ON THE PATIENT'S FOREHEAD AND WHAT I CAN TELL FROM THE CHARTING, THE CRNA DID USE THE TTP (THERMOREGULATION BAND OPTION SELECTED *TEMPORAL) TO CAPTURE INTRAOP TEMPS AS WELL. IN PACU, THE TTP HAD BECOME DISLODGED AND WAS NOT GIVING CORRECT TEMPERATURES, SO THE PACU NURSE REMOVED THE TTP SENSOR TO REPOSITION IT TO RE-PLACE IT ON THE PATIENT'S FOREHEAD AREA AND NOTICED THAT THERE WERE 4 SMALL DARK SQUARES ON THE PATIENT'S SKIN THAT ALIGNED WITH THE SENSORS ON THE TTP."
Additional Manufacturer Narrative
A USER FACILITY REPORTED, THE TEAMS PLACED THE TTP IN PREOP ON THE PATIENTS FOREHEAD AND WHAT I CAN TELL FROM THE CHARTING, THE CRNA DID USE THE TTP (THERMOREGULATION BAND OPTION SELECTED *TEMPORAL) TO CAPTURE INTRAOP TEMPS AS WELL. IN PACU, THE TTP HAD BECOME DISLODGED AND WAS NOT GIVING CORRECT TEMPERATURES, SO THE PACU NURSE REMOVED THE TTP SENSOR TO REPOSITION IT TO RE-PLACE IT ON THE PATIENTS FOREHEAD AREA AND NOTICED THAT THERE WERE 4 SMALL DARK SQUARES ON THE PATIENTS SKIN THAT ALIGNED WITH THE SENSORS ON THE TTP." DEROYAL INDUSTRIES, INC. REQUESTED RETURN OF THE DEVICE, AND RECEIVED IT ON 8/26/2025 TO SEND TO THE SUPPLIER, MEDISIM AS DEROYAL DOES NOT HAVE THE EQUIPMENT TO TEST THE DEVICE. SIMILARLY, NO INVENTORY WAS CHECKED AS DEROYAL DOESN'T HAVE THE PROPER EQUIPMENT TO TEST. A COMPLAINT TO SALES RATIO WAS CONDUCTED FROM 12/2023 TO 9/2025 AND FOUND TO BE 2.065%. A SUPPLIER CORRECTIVE ACTION REQUEST (SCAR) WILL BE ISSUED TO THE SUPPLIER, MEDISIM, LTD. MEDISIM WAS SENT THE SAMPLE ON 8/26/2025. AFTER INSPECTION AND TESTING IT WAS DETERMINED THAT THE SENSOR UNIT WAS MISSING THE BIO-ADHESIVE LAYER. ROOT CAUSE: THE BIO-ADHESIVE LAYER WAS MISSING FROM THE SENSOR UNIT IN USE. CORRECTIVE AND PREVENTIVE ACTIONS: MEDISIM ADDED A 100% IN PROCESS INSPECTION TO ENSURE BIO-ADHESIVE USED. THEY ARE ALSO WORKING ON A DESIGN WHERE THE SENSORS FACING UPWARDS AWAY FROM SKIN AS WELL AS EXTRA PROTECTION IN THE USB POWER ADAPTOR CABLE. THESE CHANGES ARE CURRENTLY IN ENGINEERING, DUE FOR PRODUCTION Q1/26. DEROYAL WILL CONTINUE TO MONITOR FOR TRENDS AROUND THIS ITEM AND ISSUE. THIS INVESTIGATION IS COMPLETE AT THIS TIME. NO FURTHER INFORMATION IS AVAILABLE AT THIS TIME. WE WILL PROVIDE FOLLOW UP REPORT IF ADDITIONAL INFORMATION BECOMES AVAILABLE.