inforMED
MalfunctionFPK

RECONSTITUTION ACCESSORIES

Received Jun 17, 2016 · Event occurred Feb 17, 2015

Report 2523676-2016-00375 · MDR key 5733159

Device

Generic name

Reconstitution Accessories

Catalog number

7O5993

Lot number

0061389250

Product problems

  • Hole In Material
  • Device Packaging Compromised

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

(B)(4). THE ACTUAL DEVICE INVOLVED IN THE REPORTED INCIDENT WAS NOT RETURNED FOR EVALUATION. HOWEVER, THE FACILITY SENT A PHOTO DEPICTING THREE PACKAGES, INDICATING THE REPORTED LOT # 0061389250, IN WHICH THE PAPER BACKING OF THE BLISTER PACKAGE WAS TORN/RIPPED NEAR THE MIDDLE OF THE PACKAGE. DUE TO THIS ISSUE, THE PACKAGING LINE FOR THIS PRODUCT WAS INSPECTED AND REVIEWED. THE CURRENT BOX SIZE AND PACKAGING CONFIGURATION WAS VALIDATED AND FOUND TO BE SUFFICIENT FOR THIS PRODUCT. THERE HAVE BEEN NO CHANGES TO THE PACKAGING CONFIGURATION OR BLISTER SIZE SINCE. THIS BLISTER PACKED PRODUCT IS SHIPPED TO A WHOLESALE MEDICAL DISTRIBUTION COMPANY, WHERE IT IS PACKAGED INTO A KIT. SINCE THE REPORTED ISSUE WAS OBSERVED AT THE END USER FACILITY, IT COULD NOT BE DEFINITIVELY DETERMINED WHERE IN THE PACKAGING/SHIPPING/HANDLING PROCESS THIS ISSUE OCCURRED. ALTHOUGH OUR PACKAGING IS TESTED TO ASTM STANDARDS DURING DEVELOPMENT TO ENSURE THAT THEY WILL MAINTAIN INTEGRITY UNDER NORMAL TO STRENUOUS SHIPPING CONDITIONS, EXCESSIVE HANDLING MAY RESULT IN SOME DAMAGE. REVIEW OF THE DISCREPANCY MANAGEMENT SYSTEM DATABASE PERFORMED FOR THE REPORTED LOT NUMBER DID NOT REVEAL ANY ABNORMALITIES OR NONCONFORMANCES OF THIS NATURE. NO ADVERSE QUALITY TRENDS OF THIS NATURE WERE IDENTIFIED DURING THE COMPLAINT REVIEW PROCESS FOR THE REPORTED CATALOG NUMBER OR LOT NUMBER. IF ADDITIONAL PERTINENT INFORMATION BECOMES AVAILABLE A FOLLOW-UP REPORT WILL BE FILED.

Description of Event or Problem

AS REPORTED BY THE USER FACILITY: EVENT # 3: REPORTS 3 OUT OF 12 PACKAGES OF THE RECONSTITUTION ACCESSORIES HAD HOLES PUNCHED IN THEM, MAKING THEM NO LONGER STERILE.