inforMED
MalfunctionKDP

ISU, BSC, STD, CW DOM

Received Oct 9, 2014 · Event occurred May 12, 2014

Report 1419185-2014-00004 · MDR key 4181731

Device

Generic name

Vacuum Regulator

Model number

8700-0000-801

Lot number

ISU137461

Product problems

  • Material Integrity Problem

Patient

Not reported

  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

THIS MALFUNCTION WAS PREVIOUSLY REPORTED ON (B)(6) 2014 (MFR REPORT # 1419185-2014-00003), HOWEVER, MULTIPLE DEVICES WERE INCLUDED ON THAT REPORT IN ERROR. THE DEVICE IS A VACUUM REGULATOR INTENDED TO REGULATE SUCTION TO REMOVE BODY FLUIDS. ON (B)(6) 2014, WAS NOTED THAT (B)(6) DEVICES WHICH HAD BEEN RETURNED FOR REPAIR CONTAINED DIAPHRAGMS WHICH HAD SIGNIFICANT TEARS IN THEM AFTER DEVICE LIFE OF LESS THAN 6 MONTHS. AT THE TIME ON QA AWARENESS ON (B)(6) 2014, PREVIOUS RETURNS WERE REVIEWED FURTHER TO DETERMINE IF ANY OTHER NEWER DEVICES HAD BEEN RETURNED WITH CONFIRMED DAMAGED DIAPHRAGMS. (B)(6) ADD'L DEVICE WAS NOTED. IT HAS BEEN DETERMINED THAT A TEAR IN THE REGULATOR DIAPHRAGM WHILE IN USE (AFTER VACUUM HAS BEEN SET) COULD RESULT IN AN INCREASE IN VACUUM TO THE PT THAN WHAT HAD BEEN ORIGINALLY SET.

Additional Manufacturer Narrative

DEVICE IS A VACUUM REGULATOR. THE DEVICE ACHIEVES ITS FUNCTION VIA A REGULATOR MODULE THAT IS EQUIPPED WITH A DIAPHRAGM. THE USER FILED A COMPLAINT THAT THE REGULATOR GAGE WAS JUMPY. DURING THE INVESTIGATION OF THE RETURNED DEVICES, IT WAS DISCOVERED THAT THE MALFUNCTIONING UNITS HAD THEIR DIAPHRAGM TORN. THE USER DID NOT REPORT ANY PT INVOLVEMENT NOR ANY ADVERSE EVENT. THE USER ALSO DID NOT FILE A FORM FDA-3500A. THE MFR IS FILING FORM FDA-3500A BECAUSE THIS WAS A MALFUNCTION THAT IF IT WERE TO RECUR, IT WOULD HAVE THE POTENTIAL TO CAUSE SOME PT HARM. INVESTIGATION INTO THE ROOT CAUSE IN ON-GOING AS OF THE DATE OF THIS REPORT AND IT HAS NOT YET BEEN DETERMINED THE EXTENT TO WHICH REMEDIAL ACTION WOULD BE APPROPRIATE TO PREVENT AN UNREASONABLE RISK OF SUBSTANTIAL HARM TO PUBLIC HEALTH.

Remedial action

  • Repair