WARMER DRAPE
Received Apr 8, 2016
Report 8043817-2016-00028 · MDR key 5565225
Device
Generic name
Fluid Warming And Slush Drapes
Manufacturer
Microtek Dominicana, S.a.Model number
ORS-300NLot 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.