inforMED
InjuryLIO

AFFIRM¿ VPIII AMBIENT TEMPERATURE TRANSPORT SYSTEM

Received Oct 26, 2016 · Event occurred Oct 5, 2016

Report 9610847-2016-00040 · MDR key 6058923

Device

Generic name

Device, Specimen Collection

Catalog number

446255

Lot number

UNKNOWN

Product problems

  • Break

Patient

Not reported

  • Exposure to Body Fluids
  • Injury
  • Exposure to Body Fluids
  • Injury

Narrative

Additional Manufacturer Narrative

AFFIRM VPIII AMBIENT TEMPERATURE TRANSPORT SYSTEM IS A STERILE READY-TO-USE SYSTEM INTENDED FOR THE COLLECTION, TRANSPORT AND PRESERVATION OF VAGINAL SPECIMENS FOR USE ONLY WITH THE AFFIRM VPIII MICROBIAL IDENTIFICATION TEST. THE AFFIRM VPIII AMBIENT TEMPERATURE TRANSPORT SYSTEM (ATTS) SHOULD BE USED WITH THOSE SPECIMENS WHERE TRANSPORT TIMES ARE EXPECTED TO EXCEED 1 H AT AMBIENT TEMPERATURE (15 ¿ 30°C) OR 4 H AT REFRIGERATED TEMPERATURES (2 ¿ 8°C). BD MOLECULAR QUALITY INITIATED INVESTIGATION ON A CUSTOMER COMPLAINT FOR AN AFFIRM ATTS INJURY (FINGER PUNCTURE) DURING SPECIMEN PROCESSING DUE TO GLASS IN THE SPECIMEN PROCESSING TUBE. IT WAS CONFIRMED THAT THE END USER FOUND GLASS IN THE SPECIMEN COLLECTION TUBE. QUALITY INVESTIGATION REQUIRED REVIEW OF THE AFFIRM ATTS PACKAGE INSERT AND AFFIRM COLLECTION POSTER. PER REVIEW OF THE AFFIRM PACKAGE INSERT AND COLLECTION POSTER, IT WAS DETERMINED THAT THE AFFIRM COLLECTION SITE WAS NOT FOLLOWING THE AFFIRM ATTS PACKAGE INSERT OR AFFIRM COLLECTION POSTER INSTRUCTIONS. THE COLLECTION SITE WAS CRUSHING THE ATTS GLASS AMPOULE (AS INSTRUCTED), OPENING THE ATTS CAP AND POURING THE GLASS INTO THE AFFIRM SAMPLE COLLECTION TUBE (NOT INSTRUCTED). THE AFFIRM PACKAGE INSERT AND AFFIRM COLLECTION POSTER DOES NOT INSTRUCT COLLECTION SITES TO OPEN THE ATTS VIAL AND POUR THE GLASS INTO THE COLLECTION TUBE. BD WILL UPDATE THE AFFIRM COLLECTION POSTER TO PROVIDE FURTHER CLARIFICATION ON THE INSTRUCTIONS OF USE WITH AFFIRM ATTS. BD MOLECULAR QUALITY WILL CONTINUE TO CLOSELY MONITOR FOR TRENDS ASSOCIATED WITH AFFIRM ATTS GLASS INJURY. (B)(4). DEVICE NOT RETURNED TO MANUFACTURER.

Description of Event or Problem

THE CUSTOMER REPORTED THAT WHILE PROCESSING A PATIENT SPECIMEN TRANSPORT TUBE FROM A AFFIRM VPIII AMBIENT TEMPERATURE TRANSPORT SYSTEM, GLASS PIERCED THROUGH THE TUBE AND INJURED A TECHNICIAN'S THUMB. THE TECHNICIAN REPORTED THE INCIDENT AND RECEIVED BASIC FIRST AID AND CARE ACCORDING TO THE FACILITY'S BLOOD BORNE PATHOGENS POLICY. BD FOLLOWED UP WITH THE CUSTOMER ON OCTOBER 17, 2016 AND THE INJURED TECHNICIAN IS REPORTED TO BE DOING WELL.