AFFIRM VPIII AMBIENT TEMPERATURE TRANSPORT
Received Sep 26, 2012 · Event occurred Aug 30, 2012
Report 1119779-2012-00010 · MDR key 2767034
Device
Product problems
- Appropriate Device Problem Term/Code Not Available
Patient
Not reported
- No Code Available
Narrative
Description of Event or Problem
A TECH WAS PROCESSING A SPECIMEN FOR TESTING ON THE AFFIRM SYSTEM. THE FACILITY RECEIVES SAMPLES FROM MANY DIFFERENT DOCTORS OFFICES. THIS PARTICULAR SAMPLE HAS SHARDS OF GLASS IN IT WHICH THE CUSTOMER THEORIZES CAME FROM THE BROKEN TRANSPORT AMPULE AT THE COLLECTION SITE WITH THE GLASS MAKING ITS WAY INTO THE SAMPLE TUBE. THE TUBE AT THE TESTING SITE CUT HER FINGER WHEN SHE WAS SQUEEZING THE TUBE TO DISPENSE THE SAMPLE FOR TESTING. THE CUT CAME FROM A SHARD OF GLASS THAT POKED THROUGH THE PLASTIC TUBE. THE TECH WAS TREATED BY OCCUPATIONAL HEALTH AT HER FACILITY. NO STITCHES WERE REQUIRED, BUT SHE DID RECEIVE SCREENING FOR BLOOD BORNE PATHOGENS. NO ADDITIONAL SIDE EFFECTS HAVE BEEN REPORTED.
Additional Manufacturer Narrative
THIS PRODUCT CONTAINS AN AMPULE OF REAGENT. THE AMPULE IS CRUSHED AND THE REAGENT IS RELEASED THROUGH A DROPPER INTO A PT SAMPLE. RETURNS WERE UNAVAILABLE FOR ANALYSIS. A REVIEW OF THE COMPLAINT NOTES INDICATES A MISUSE OF THE PRODUCT WHERE THE PROCEDURE, IN THE PRODUCT INSERT, WAS NOT FOLLOWED AT THE POINT OF SPECIMEN COLLECTION. THE PRESENCE OF GLASS IN THE COLLECTION TUBE WOULD INDICATE THAT THE DROPPER TIP WAS REMOVED WHEN DISPENSING THE TRANSFER REAGENT INTO THE COLLECTION TUBE. IF THE PROCEDURE, AS INDICATED IN THE PRODUCT INSERT, WAS FOLLOWED, NO GLASS WOULD'VE BEEN PRESENT IN THE TUBE. ALL CONTENTS IN THE COLLECTION TUBE SHOULD BE TREATED AS PATHOGENICALLY HAZARDOUS MATERIAL, AS INSTRUCTED IN THE PACKAGE INSERT "WARNING: PATHOGENIC MICROORGANISMS, INCLUDING HEPATITIS VIRUS AND HUMAN IMMUNODEFICIENCY VIRUS, MAY BE PRESENT IN CLINICAL SPECIMENS. "STANDARD PRECAUTIONS" AND INSTITUTIONAL GUIDELINES SHOULD BE FOLLOWED IN HANDLING ALL ITEMS CONTAMINATED WITH BLOOD AND OTHER BODY FLUIDS." THE COMPLAINT IS NOT CONFIRMED FOR ANY PRODUCT DEFECT. BD WILL CONTINUE TO MONITOR THIS TYPE OF ISSUE.