inforMED
MalfunctionOGJ

ARROW CONTINUOUS PERIPHERAL NERVE BLOCK KIT

Received Sep 17, 2015 · Event occurred Sep 3, 2015

Report 1036844-2015-00414 · MDR key 5084720

Device

Generic name

Anesthesia Conduction Kit

Catalog number

ASK-20608-ROP

Lot number

23F15E0139

Product problems

  • Crack
  • Fluid/Blood Leak

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

(B)(4). THE CUSTOMER RETURNED ONE 20GA STIMUCATH FOR INVESTIGATION. A VISUAL EXAM WAS PERFORMED AND IT WAS OBSERVED THAT THE CATHETER WAS USED AS BIOLOGICAL MATERIAL COULD BE SEEN ON BOTH THE DISTAL AND PROXIMAL EXPOSED COILS. THE COILS AT THE PROXIMAL END WERE DAMAGED. THE SAFETY RIBBON WAS PRESENT AND ATTACHED, HOWEVER, THE MOST DISTAL TIP OF THE COILS WERE UNRAVELED. NO OTHER DEFECTS WERE OBSERVED. FUNCTIONAL TESTING WAS ALSO PERFORMED AND NO LEAKS WERE DETECTED. THE LOT NUMBER PROVIDED BY THE CUSTOMER IS NOT A VALID LOT NUMBER FOR THE REPORTED PRODUCT CODE. A DEVICE HISTORY RECORD REVIEW WAS CONDUCTED BASED ON A LOT NUMBER (23F15G1135) FROM SALES HISTORY OF THE CUSTOMER, AND THERE WERE NO RELEVANT FINDINGS. THE REPORTED COMPLAINT OF A CATHETER LEAK WAS NOT CONFIRMED BASED ON THE SAMPLE RECEIVED. THE RETURNED CATHETER PASSED A FUNCTIONAL LEAK TEST AND NO CRACKS WERE DETECTED ON THE CATHETER BODY. A DHR REVIEW WAS PERFORMED ON THE EPIDURAL CATHETER WITH NO EVIDENCE TO SUGGEST A MANUFACTURING RELATED CAUSE. THERE WERE NO FUNCTIONAL ISSUES FOUND WITH THE RETURNED SAMPLE.

Description of Event or Problem

THE CUSTOMER ALLEGES THAT WHEN THE DOCTOR WAS INJECTING THE DRUG INTO THE CATHETER, HE NOTICED THAT THE CATHETER HAD CRACKS ALL THE WAY DOWN. THE CATHETER LEAKED ALONG THE CATHETER. NO PATIENT INJURY OR CONSEQUENCE.

Additional Manufacturer Narrative

(B)(4). THE DEVICE SAMPLE WAS NOT RETURNED FOR EVALUATION AT THE TIME OF THIS REPORT.

Description of Event or Problem

THE CUSTOMER ALLEGES THAT WHEN THE DOCTOR WAS INJECTING THE DRUG INTO THE CATHETER, HE NOTICED THAT THE CATHETER HAD CRACKS ALL THE WAY DOWN. THE CATHETER LEAKED ALONG THE CATHETER. NO PATIENT INJURY OR CONSEQUENCE.