inforMED
MalfunctionLHC

WARMER DRAPE

Received May 31, 2017

Report 8043817-2017-00014 · MDR key 6602578

Device

Generic name

Fluid Warming And Slush Drapes

Model number

ORS-100

Lot number

UNKNOWN

Product problems

  • Fluid/Blood Leak
  • Hole In Material

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

NO LOT NUMBER, SAMPLE, OR PICTURE HAVE BEEN RECEIVED FOR THIS REPORTED NON CONFORMITY. THE INVESTIGATION IS PENDING RECEIPT OF A SAMPLE. NO ACTIONS HAVE BEEN TAKEN AT THIS TIME.

Description of Event or Problem

END USER NOTICED THAT THERE WAS A HOLE IN THE DRAPE AT THE END OF THE PROCEDURE. THERE WAS A LOT OF FLUID THAT HAD LEAKED INTO THE BASIN. NO PATIENT INJURY OR TREATMENT WAS REPORTED FOR THE INCIDENT.

Additional Manufacturer Narrative

A SAMPLE WAS RECEIVED BUT INADVERTENTLY MISPLACED. SINCE A LOT NUMBER WAS NOT PROVIDED, A DEVICE HISTORY RECORD REVIEW WAS NOT COMPLETED. SINCE A LOT NUMBER WAS NOT PROVIDED AND THE SAMPLE COULD NOT BE REVIEWED, THE NON CONFORMITY WAS NOT ABLE TO BE CONFIRMED AS A PERSONNEL, PROCESS, OR MATERIAL ISSUE. BECAUSE A SAMPLE WAS NOT REVIEWED AND THE DEVICE HISTORY RECORD REVIEW COULD NOT BE PERFORMED, THE NON CONFORMITY COULD NOT BE CONFIRMED. NO ADDITIONAL ACTIONS WILL BE TAKEN AT THIS TIME. MELTS, THOUGH UNCOMMON, CAN OCCUR WHEN THE WARMER IS NOT DRAPED PROPERLY, NOT TURNED OFF BY USING THE POWER BUTTON, AND/OR THERE IS INSUFFICIENT FLUID IN THE WARMER BASIN, CONTRARY TO THE OPERATIONS MANUAL, PRODUCT LABELING, PRODUCT INSERT AND IN-SERVICE PRESENTATIONS.

Description of Event or Problem

END USER NOTICED THAT THERE WAS A HOLE IN THE DRAPE AT THE END OF THE PROCEDURE. THERE WAS A LOT OF FLUID THAT HAD LEAKED INTO THE BASIN. NO PATIENT INJURY OR TREATMENT WAS REPORTED FOR THE INCIDENT.