inforMED
MalfunctionKRX

3K-CAL HEMATOLOGY CALIBRATOR/MULTIPLE

Received Jan 19, 2012 · Event occurred Dec 29, 2011

Report 1061932-2012-00181 · MDR key 2421940

Device

Generic name

Calibrator For Cell Indices

Model number

ACT 5 CALIBRATOR

Catalog number

7547175

Lot number

CX436

Product problems

  • Leak/Splash
  • Loose or Intermittent Connection

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Description of Event or Problem

CUSTOMER CALLED ON (B)(6) 2011 REPORTING THAT UPON OPENING A SHIPMENT OF THE ACT 5 CALIBRATOR, ONE OF THE VIAL WAS FOUND TO HAVE LEAKED (APPROXIMATELY 2 ML) INSIDE THE PRODUCT BOX. CUSTOMER STATED THAT THE PACKAGE WAS OPENED TO FIND IF THE VIAL WAS BROKEN BUT FOUND THAT THE VIAL WAS INTACT. CUSTOMER MENTIONED THAT THE REASON FOR THE LEAK WAS THAT THE CAP WAS NOT SCREWED ON TIGHTLY ON ONE OF THE 2 VIALS. THE PACKAGE WAS DISPOSED OF IN CUSTOMER'S BIOHAZARD CONTAINER AND HOTLINE HAD ARRANGED FOR A REPLACEMENT. CUSTOMER WAS WEARING PERSONAL PROTECTIVE EQUIPMENT CONSISTING OF A LAB COAT AND GLOVES AT THE TIME OF THE EVENT AND NO ONE WAS EXPOSED TO THE LEAK. CUSTOMER ALSO REPORTED THAT NO INJURY HAD RESULTED FROM THE EVENT. ROOT CAUSE FOR THE LEAK IS POTENTIALLY ATTRIBUTED TO THE CAP NOT BEING SCREWED ON TIGHTLY ONTO THE VIAL.

Additional Manufacturer Narrative

METHOD: EVALUATION WAS DONE BY THE CUSTOMER. CUSTOMER STATED THAT THE SEASON FOR THE LEAK WAS THAT THE CAP WAS NOT SCREWED ON TIGHTLY ON ONE OF THE TWO VIALS. (B)(4).