inforMED
MalfunctionLHC

WARMER DRAPE

Received Mar 24, 2016 · Event occurred Jan 22, 2016

Report 8043817-2016-00026 · MDR key 5523111

Device

Generic name

Fluid Warming And Slush Drapes

Model number

ORS-100N

Lot number

SEE H10

Product problems

  • Melted

Patient

Not reported

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

PRODUCT SAMPLE WAS RECEIVED ON 3/4/2016 AND REVIEWED ON 3/11/2016 BY QUALITY DEPARTMENT. THE DRAPE WAS SOAKED IN BLEACH WATER FOR 2 HOURS, RINSED, LET DRY, EXAMINED AND PICTURES TAKEN. THREE BURN MARKS WERE CIRCLED TO THE LEFT OF THE CENTER. ONE BURN MARK WAS AT 4 INCHES FROM THE TOP LEFT OF CENTER, 1 WAS AT 4 INCHES FROM THE LEFT OF CENTER AND 1 WAS AT ABOUT 4 1/2 INCHES FROM THE BOTTOM LEFT OF CENTER. WATER HAS BEEN ADDED TO DRAPE TO SEE IF DRAPE HAD ANY LEAKS. NO LEAK WAS FOUND ON DRAPE. THE SAMPLE DRAPE ONLY HAD BURN MARKS, THERE WAS NO BURN HOLE. 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 WARMER IS OPERATED CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT AND IN-SERVICE PRESENTATIONS.

Description of Event or Problem

THE IRRIGATION WARMING DRAPE MELTED. FOUND AFTER THE CASE, DID NOT MELT ALL THE WAY THROUGH. NO PATIENT INJURY OR SAFETY CONCERNS.

Additional Manufacturer Narrative

PRODUCT SAMPLE WAS RECEIVED ON 3/4/2016 AND REVIEWED ON 3/11/2016 BY QUALITY DEPARTMENT. THE DRAPE WAS SOAKED IN BLEACH WATER FOR 2 HOURS, RINSED, LET DRY, EXAMINED AND PICTURES TAKEN. THREE BURN MARKS WERE CIRCLED TO THE LEFT OF THE CENTER. ONE BURN MARK WAS AT 4 INCHES FROM T HE TO LEFT OF CENTER, 1 WAS AT 4 INCHES FROM THE LEFT OF CENTER AND 1 WAS AT ABOUT 4 1/2 INCHES FROM THE BOTTOM LEFT OF CENTER. WATER HAS BEEN ADDED TO DRAPE TO SEE IF DRAPE HAD ANY LEAKS. NO LEAK WAS FOUND ON DRAPE. THE SAMPLE DRAPE ONLY HAD BURN MARKS, THERE WAS NO BURN HOLE. 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 WARMER IS OPERATED CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT, AND IN-SERVICE PRESENTATIONS.

Description of Event or Problem

THE IRRIGATION WARMING DRAPE MELTED. FOUND AFTER THE CASE, DID NOT MELT ALL THE WAY THROUGH. NO PATIENT INJURY OR SAFETY CONCERNS.