inforMED
MalfunctionLHC

WARMER DRAPE

Received Feb 18, 2016

Report 8043817-2016-00017 · MDR key 5445936

Device

Generic name

Fluid Warming And Slush Drapes

Model number

ORS-100N

Lot number

D152501 D143091

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

NO PRODUCT HAS BEEN RETURNED. SINCE NO DEVICE WAS RETURNED FOR ANALYSIS, THE ROOT CAUSE FOR THE EVENT HAS NOT BEEN DETERMINED.

Description of Event or Problem

ECOLAB-MICROTEK SALES REPRESENTATIVE REPORTED THAT THE DRAPE LEAKED INTO THE WARMING PAN. ECOLAB-MICROTEK REPRESENTATIVE STATED THEY DISCOVERED THE LEAK AFTER THE CASE. THE DRAPE WAS USED DURING THE PROCEDURE. THERE WERE NO PATIENT INJURY AND TREATMENT REPORTED OF THE INCIDENT.

Additional Manufacturer Narrative

NO PRODUCT HAS BEEN RETURNED. SINCE NO DEVICE WAS RETURNED FOR ANALYSIS, THE ROOT CAUSE FOR THE EVENT HAS NOT BEEN DETERMINED. FOLLOW UP #1: THE DHR WAS REVIEWED FOR LOT D152503 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND IT WAS MANUFACTURED ON 09/07/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THE DHR WAS REVIEWED FOR LOT D143091 AND IT WAS SEEN THAT THIS LOT HAD 4800 PCS AND IT WAS MANUFACTURED ON 11/05/2014. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING OR FINAL INSPECTION. BASED ON THE DHR REVIEW THE NON CONFORMITY DOES NOT APPEAR TO BE THE RESULT OF A PERSONNEL, PROCESS OR MATERIAL ISSUE. DUE TO RECEIVING NO SAMPLE THE NON CONFORMITY COULD NOT BE PHYSICALLY CONFIRMED. 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, CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT AND IN-SERVICE PRESENTATIONS.

Description of Event or Problem

SALES REP REPORTS THAT THE DRAPE LEAKED INTO THE WARMING PAN. REP STATED THEY DISCOVERED THE LEAK AFTER THE CASE. THE DRAPE WAS USED DURING THE PROCEDURE. NO PATIENT INJURY OR TREATMENT WERE REPORTED FOR THE INCIDENT.