inforMED
MalfunctionLHC

WARMER DRAPE

Received Apr 8, 2016

Report 8043817-2016-00028 · MDR key 5565225

Device

Generic name

Fluid Warming And Slush Drapes

Model number

ORS-300N

Lot number

SEE H10

Product problems

  • Hole In Material

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

DHR WAS REVIEWED AND IT WAS SEEN THAT THIS LOT HAD 4800 PCS AND IT WAS MANUFACTURED ON 7/10/2015. NO DEFECT WAS REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. SINCE NO DEVICE WAS RETURNED FOR ANALYSIS/REVIEW, THE ROOT CAUSE FOR THE EVENT HAS NOT BEEN DETERMINED. FOLLOW UP #1: LOT 1043776 WAS REPORTED IN THIS COMPLAINT. THIS IS THE STERILE LOT FROM MEDICAL ACTION WHICH CORRESPONDS TO MICROTEK NONSTERILE LOTS D152781 AND D152751 THE DHR WAS REVIEWED FOR LOT D152781 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND WAS MANUFACTURED ON 10/5/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. THE DHR WAS REVIEWED FOR LOT D152751 AND IT WAS SEEN THAT THIS LOT HAD 4800PCS AND IT WAS MANUFACTURED ON 10/2/2015. NO DEFECTS WERE REPORTED IN PROCESS, PACKAGING, OR FINAL INSPECTION. SAMPLES WERE RETURNED ON 3/31/16 FROM LOT 1043776. THE REPORTED DEFECT WAS NOT OBSERVED IN THE RETURNED SAMPLES. AFTER PROCESS EVALUATION NO POSSIBLE ROOT CAUSE FOR THE DEFECT REPORTED COULD BE IDENTIFIED. ALSO, THE DEFECT COULD NOT BE REPLICATED AS NO DEFECTIVE SAMPLE WAS RETURNED FOR EVALUATION. THIS COMPLAINT IS CONSIDERED AN ISOLATED INCIDENT.

Description of Event or Problem

THE CUSTOMER IS REPORTING THAT THEY USED ONE IN A WARMER FOR A SURGICAL CASE. HAD LAP SPONGES AND ONE SMOOTH BOTTOM PLASTIC BOWL IN WARMER FOR A 3 HOUR CASE. AT THE END OF THE CASE THE CUSTOMER REMOVED THE LAPS AND BOWL, GATHERED SIDE TO TAKE WATER IN THE DRAPE TO THE SINK. BEFORE DUMPING THE CONTENTS THE CUSTOMER NOTICED IT WAS DRIPPING, THEY DRIED THE BOTTOM OF THE DRAPE STILL HOLDING THE WATER AND WAITED A SMALL AMOUNT OF TIME NOTICING IT WAS DRIPPING REALLY SLOWLY. THUS THERE WAS A SMALL HOLE IN THE DRAPE. THERE WERE NO PATIENT INJURY AND TREATMENT REPORTED OF THE INCIDENT.

Additional Manufacturer Narrative

DHR WAS REVIEWED AND IT WAS SEEN THAT THIS LOT HAD (B)(4) PCS AND IT WAS MANUFACTURED ON 7/10/2015. NO DEFECT WAS REPORTED IN PROCESS, PACKAGING OR FINAL INSPECTION. SINCE NO DEVICE WAS RETURNED FOR ANALYSIS/REVIEW, THE ROOT CAUSE FOR THE EVENT HAS NOT BEEN DETERMINED.

Description of Event or Problem

THE CUSTOMER IS REPORTING THAT THEY USED ONE IN A WARMER FOR A SURGICAL CASE. HAD LAP SPONGES AND ONE SMOOTH BOTTOM PLASTIC BOWL IN WARMER FOR A 3 HOUR CASE. AT THE END OF THE CASE THE CUSTOMER REMOVED THE LAPS AND BOWL, GATHERED SIDE TO TAKE WATER IN THE DRAPE TO THE SINK. BEFORE DUMPING CONTENTS, THE CUSTOMER NOTICED IT WAS DRIPPING. THEY DRIED THE BOTTOM OF THE DRAPE STILL HOLDING THE WATER AND WAITED A SMALL AMOUNT OF TIME NOTICING IT WAS DRIPPING REALLY SLOWLY. THUS THERE WAS A SMALL HOLE IN THE DRAPE. THERE WERE NO PATIENT INJURY AND TREATMENT REPORTED OF THE INCIDENT.