inforMED
MalfunctionLHC

WARMER DRAPE

Received Feb 18, 2016

Report 8043817-2016-00016 · MDR key 5445438

Device

Generic name

Fluid Warming And Slush Drapes

Model number

ORS-300N

Lot number

SEE H10

Product problems

  • Leak/Splash

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

SAMPLE DRAPE WAS SOAKED IN BLEACH FOR 45 MINUTES TO 1 HOUR, RINSED, LET DRY, CHECKED USED SAMPLE AND TOOK PHOTOS. THEN VISUALLY CHECKED FOR HOLES OR LEAKS. NO HOLES, LEAKS OR TEARS WERE NOTED IN THE DRAPE. AFTER REVIEWING THE SAMPLE, IT HAS BEEN CONCLUDED THAT THE NON CONFORMITY (HOLE) IS A BURN. MELTS, THOUGH UNCOMMON, CAN OCCUR WHEN THE WARMER IS NOT DRAPED PROPERLY, NOT TURNED OFF BY USING THE POWER BUTTON, AND/OR THERE IS INSUFFICIENT FLUID IN THE WARMER BASIN; AND/OR IF THE WARMER IS OPERATED CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT AND IN-SERVICE PRESENTATIONS.

Description of Event or Problem

AN END USER REPORTED THAT THE DRAPES OM-ORS-300 WERE LEAKING DURING SCOPE WARMING PROCEDURES.

Additional Manufacturer Narrative

SAMPLE DRAPE WAS SOAKED IN BLEACH FOR 45 MINUTES TO 1 HOUR, RINSED, LET DRY, CHECKED USED SAMPLE AND TOOK PHOTOS. THEN VISUALLY CHECKED FOR HOLES OR LEAKS. NO HOLES, LEAKS, OR TEARS WERE NOTED IN THE DRAPE. AFTER REVIEWING THE SAMPLE, IT HAS BEEN CONCLUDED THAT THE NON CONFORMITY (HOLE) IS A BURN. MELTS, THOUGH UNCOMMON, CAN OCCUR WHEN THE WARMER IS NOT DRAPED PROPERLY, NOT TURNED OFF BY USING THE POWER BUTTON, AND/OR THERE IS INSUFFICIENT FLUID IN THE WARMER BASIN; AND/OR IF THE WARMER IS OPERATED CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT AND IN-SERVICE PRESENTATIONS. FOLLOW UP #1: AN UNUSED DRAPE WAS RETURNED TO THE MANUFACTURER WITH THE USED DRAPE. THE UNUSED DRAPE DID NOT HAE ANY BURNS, HOLES, OR TEARS. LOT 1041696 WAS REPORTED FOR THIS COMPLAINT. THIS IS THE STERILE LOT FROM MEDICAL ACTION WHICH CORRESPONDS TO THE MICROTEK NON STERILE LOTS D151391, D151401, D152661, D152591 THE DHR WAS REVIEWED FOR LOT D151391 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND IT WAS MANUFACTURED ON 08/20/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THIS LOT WAS MANUFACTURED IN COMBINED SHIFTS. THE DHR WAS REVIEWED FOR LOT D151401 AND IT WAS SEEN THAT THIS LOT HAD 4680PCS AND IT WAS MANUFACTURED ON 05/21/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THIS LOT WAS MANUFACTURED IN COMBINED SHIFTS. THE DHR WAS REVIEWED FOR LOT D152661 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND IT WAS MANUFACTURED ON 09/23/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THIS LOT WAS MANUFACTURED IN COMBINED SHIFTS. THE DHR WAS REVIEWED FOR LOT D152591 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND IT WAS MANUFACTURED ON 09/16/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THIS LOT WAS MANUFACTURED IN COMBINED SHIFTS. AFTER REVIEW OF THE DEVICE HISTORY RECORD AND SAMPLE REVIEW, THE NON CONFORMANCE DOES NOT APPEAR TO BE THE RESULT OF A PERSONNEL, PROCESS, OR MATERIAL ISSUE.

Description of Event or Problem

AN END USER REPORTED THAT THE DRAPES OM-ORS-300N WERE LEAKING DURING SCOPE WARMING PROCEDURES.