inforMED
InjuryFSH

JAMSHIDI BONE MARROW TRAY 11G X4 15G ASP

Received Sep 28, 2016 · Event occurred Aug 4, 2016

Report 1625685-2016-00253 · MDR key 5983269

Device

Generic name

Tray, Surgical, Needle

Manufacturer

Carefusion, Inc

Model number

BAK4511

Lot number

0000922436

Product problems

  • Sticking

Patient

Not reported

  • Needle Stick/Puncture
  • Needle Stick/Puncture

Narrative

Additional Manufacturer Narrative

(B)(4) INITIAL EMDR SUBMISSION. A FOLLOW UP EMDR WILL BE SUBMITTED UPON COMPLETION OF INVESTIGATION. (B)(4).

Description of Event or Problem

SALES REP STATED VIA EMAIL: THE USER WAS TRYING TO GET A SAMPLE OUT OF THE JAMSHIDI NEEDLE AND STUCK HER THUMB WITH THE NEEDLE (ON 2 DIFFERENT DATES). ADDITIONAL INFORMATION RECEIVED 15SEPT2016: AS I WAS NOT DIRECTLY INVOLVED, THIS IS WHAT WAS REPORTED TO ME. FIRST INCIDENT WAS APPROX. 1ST WK OF (B)(6). DR. (B)(6) PERFORMED BONE MARROW PROCEDURE. WAS HAVING DIFFICULTY REMOVING SAMPLE FM CORING NEEDLE. WAS REALLY JAMMED IN. WAS PUSHING FOR APPROX. 10 MINS AND COULD NOT GET IT TO BUDGE. PASSED IT OFF TO HIS MA WHO CONTINUED TO WORK WITH IT AND IN THE PROCESS SHE SOMEHOW NICKED/SCRAPED HERSELF W/BONE MARROW NEEDLE. WAS SUCCESSFUL IN GETTING CORE SAMPLE OUT AND DIDN'T EVEN REALIZE SHE HAD SCRAPED HERSELF UNTIL SHE WENT TO WASH HANDS, FELT STING, AND DID CLOSE INSPECTION. SO THIS DID NOT OCCUR DURING ACTUAL PT PROCEDURE WHICH WAS COMPLETED, THERE WAS NO PT INVOLVEMENT. OF NOTE BOTH TIMES PROTOCOL WAS FOLLOWED AND MA WENT TO HR FOR HEALTH SCREENING FOLLOW UP. MA WAS INTERVIEWED REGARDING BONE MARROW POLICY AND PROCEDURE W/EMPHASIS ON SAFETY. SECOND NEEDLE STICK IS CAPTURED IN (B)(4).

Additional Manufacturer Narrative

(B)(4) FOLLOW UP EMDR FOR DEVICE EVALUATION. WITH NO SAMPLE OR PICTURE TO EVALUATE, THE INVESTIGATION WAS UNABLE TO CONFIRM THIS FAILURE MODE. THE DHR WAS REVIEWED AND NO ANOMALIES WERE FOUND DURING THE DATE OF PRODUCTION; THEREFORE THIS COMPLAINT COULD NOT BE CONFIRMED. THE MOST PROBABLE ROOT CAUSE OF THE REPORTED COMPLAINT IS PRODUCT MISUSE, THE DHR DID NOT SHOW ANY MANUFACTURING RELATED DEFECTS AND THE TREND REPORT DID NOT REVEAL ANY ADVERSE TRENDS. THE DHR WAS REVIEWED AND NO ANOMALIES WERE FOUND DURING THE DATE OF PRODUCTION; THEREFORE THIS COMPLAINT COULD NOT BE CONFIRMED.