inforMED
MalfunctionGDZ

RETRACTABLE SAFETY SCALPEL

Received Dec 11, 2015 · Event occurred Nov 12, 2015

Report 3004605321-2015-00017 · MDR key 5291116

Device

Generic name

Handle, Scalpel

Catalog number

D4511A

Product problems

  • Premature Activation
  • Activation, Positioning or Separation Problem

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

ROOT CAUSE ANALYSIS: THE REPORTED ISSUE HAS BEEN DETERMINED TO BE A RANDOM EVENT. THE DEFECTIVE SCALPEL WAS NOT RETURNED FOR EVALUATION. IT IS UNKNOWN WHETHER THE ISSUE OCCURRED DUE TO PRE-ACTIVATION OF THE SCALPEL BLADE. CORRECTIVE ACTION AND/OR SYSTEMIC CORRECTION ACTION TAKEN: DUE TO THE INVESTIGATION AND ROOT CAUSE DETERMINATION, A CORRECTIVE ACTION HAS NOT BEEN TAKEN. INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT (CALL (B)(4)) WAS RECEIVED INDICATING THAT AN EMPLOYEE WAS STUCK IN THE FINGER BY A SCALPEL BLADE (PART NUMBER (B)(4)) UPON ATTEMPTING TO REMOVE THE DEVICE FROM THE PACKAGING. A SAMPLE OF THE DEFECTIVE DEVICE WAS NOT RETURNED TO DEROYAL FOR EVALUATION. THE QUALITY CONTROL COMPLAINT SPECIALIST REVIEWED THE ROUTING INSTRUCTIONS FOR PART NUMBER (B)(4) ABOUT THE DEVICE PACKAGING. THE ROUTING INSTRUCTIONS STATE THE FOLLOWING: "ASSURE THE BLADE IS COMPLETELY RETRACTED PRIOR TO PACKAGING. PLACE 100 EACH SCALPELS IN A DOUBLE POLYBAG. MAKE SURE THE SCALPELS ARE ALL TURNED IN THE SAME DIRECTION. TWIST TIE AND POLY LINERS SHALL BE CLOSED AS FIRMLY AROUND SCALPELS AS POSSIBLE. PLACE TWO POLYBAGS WITH 100 EACH SCALPELS IN THE SHIPPER CASE WITH SHARP END TOWARD EACH END OF THE BOX. PLACE ONE EACH INSERT PER CASE. PLACE OUTER CARTON LABEL ON OUTER BOX." BY PACKAGING THE PRODUCT IN THE ABOVE MENTIONED MANNER, THE DEVICES CAN BE REMOVED FROM THE SHIPPING CASE WITH THE BLADES FACING AWAY FROM THE END USER. (B)(4). PREVENTIVE ACTION: DUE TO THE INVESTIGATION AND ROOT CAUSE DETERMINATION, A PREVENTIVE ACTION HAS NOT BEEN TAKEN. DEVICE NOT RETURNED TO MANUFACTURER.

Description of Event or Problem

CARDINAL PERSONNEL WAS READY TO OPEN A BAG CONTAINING PART (B)(4). THE EMPLOYEE WAS STUCK IN THE FINGER BY A BLADE THAT WAS STICKING OUT OF THE BAG.