inforMED
MalfunctionOGP

PORTEX MINI-TRACH II - NON SELDINGER KIT

Received Apr 4, 2018 · Event occurred Mar 1, 2018

Report 3012307300-2018-00663 · MDR key 7396086

Device

Generic name

Cricothyrotomy Kit

Catalog number

100/461/000

Lot number

3457249

Product problems

  • Positioning Failure
  • Positioning Failure

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

(B)(6).

Description of Event or Problem

IT WAS REPORTED THAT AFTER INDWELLING A TUOHY NEEDLE IN A PATIENT, THE CUSTOMER ATTEMPTED TO INSERT THE GUIDEWIRE INTO IT; BUT COULDN'T WITH THE USE OF A PORTEX® MINI-TRACH® II - NON SELDINGER KIT. NO PATIENT INJURY.

Additional Manufacturer Narrative

ONE TUOHY NEEDLE AND ONE GUIDE WIRE WERE PROVIDED FOR EVALUATION. THE NEEDLE WAS TESTED AND FOUND TO BE INSERTED WITHOUT RESISTANCE. THE GUIDE WIRE WAS TESTED AS WELL, AND UPON INSERTION WAS NOT FOUND TO HAVE RESISTANCE. EVERY NEEDLE RECEIVED AT SMITHS MEDICAL (B)(4) GETS INSPECTED RANDOMLY AND THERE HAVE BEEN NO DEVIATIONS IN THE INSPECTION PROTOCOL OF THE INVOLVED NEEDLE LOTS. THE REPORTED COMPLAINT WAS NOT CONFIRMED AND REVEALED NO INTRINSIC EVIDENCE TO SUGGEST A ROOT CAUSE RELATED TO MANUFACTURING.