inforMED
MalfunctionGDZ

#11 SAFETY SCALPEL

Received May 19, 2016 · Event occurred Apr 18, 2016

Report 3004605321-2016-00002 · MDR key 5667182

Device

Generic name

Handle, Scalpel

Catalog number

D4511A

Lot number

40418006

Product problems

  • Use of Device Problem
  • Device Handling Problem
  • Use of Device Problem
  • Device Handling Problem

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

ROOT CAUSE: THE REPORTED ISSUE HAS BEEN DETERMINED TO BE AN ATTENTION-BASED ERROR BY THE END USER. DEROYAL PROVIDES INSTRUCTIONS FOR USE WITH THE DEVICE AND WITHIN THE DIRECTIONS FOR USE SECTION ARE SPECIFIC INSTRUCTIONS FOR PRODUCT USE. CORRECTIVE ACTION: A CORRECTIVE ACTION HAS NOT BEEN TAKEN. INVESTIGATION SUMMARY: AN INTERNAL COMPLAINT (B)(4) WAS RECEIVED INDICATING THAT THE REPORTING CUSTOMER IS HAVING ISSUES WITH A SAFETY SCALPEL (FINISHED GOOD D4511A, LOT NUMBER 40418006). ACCORDING TO THE CUSTOMER'S REPORT, THE SCALPEL OPERATED DIFFERENTLY THAN THE USER EXPECTED AND OPENED INTO THE PALM. AS A RESULT, THE CLINICIAN SUSTAINED A LACERATION. DEROYAL SUPPLIES INSTRUCTIONS FOR USE WITH THE PRODUCT. UNDER THE DIRECTIONS FOR USE, INSTRUCTIONS ARE PROVIDED FOR HANDLING AND USAGE OF THE DEVICE. STEP 2 STATES, "GRASP THE SCALPEL AND CAREFULLY EXTEND THE BLADE BY MOVING THE BLUE SLIDE TOWARD THE TIP OF THE SCALPEL, USING THE THUMB OF THE HAND HOLDING THE SCALPEL." THE DESIGN OF THE PRODUCT CLEARLY IDENTIFIES THE DIRECTION OF THE BLADE AND MOVEMENT OF THE SLIDER. ONE END OF THE RED HANDLE IS CLOSED AND THE OTHER OPENED SO THE BLADE CAN EXTEND. WHEN RETRACTED, THE BLUE SLIDER IS POSITIONED TOWARD THE CLOSED END OF THE HANDLE. IN THIS POSITION, THE SLIDER CAN ONLY MOVE UPWARD TOWARD THE OPENED END OF THE HANDLE TO EXTEND THE BLADE. DEROYAL HAS SOLD (B)(4) EACH OF FINISHED GOOD D4511A FROM 2014 TO PRESENT. DURING THIS SAME PERIOD, (B)(4) COMPLAINTS WERE RECEIVED FOR SCALPEL STICKS OR CUTS. THIS IS A COMPLAINT-TO-SALES RATIO OF (B)(4) PERCENT. DEROYAL WILL CONTINUE TO MONITOR POST MARKET FEEDBACK AND WILL RECOGNIZE IN THE FUTURE IF A TREND DEVELOPS. PREVENTIVE ACTION: DUE TO THE INVESTIGATION AND ROOT CAUSE, A PREVENTIVE ACTION HAS NOT BEEN TAKEN. THE INVESTIGATION IS COMPLETE. IF NEW AND CRITICAL INFORMATION IS RECEIVED, THIS REPORT WILL BE UPDATED. DEVICE NOT RETURNED.

Description of Event or Problem

THE SCALPEL OPENED DIFFERENTLY THAN THE USER EXPECTED AND OPENED INTO THE PALM OF THE HAND. THE CLINICIAN SUSTAINED A LACERATION THAT BROKE THE SKIN AND REQUIRED 5 MINUTES OF COMPRESSION TO STOP THE BLEEDING. THE INJURY WAS WASHED AND A LIGHT COMPRESSION BANDAGE APPLIED. THE LACERATION HEALED AFTER A FEW DAYS.