inforMED
InjuryFBO

FLEXIBLE VIDEO CYSTOSCOPE

Received Apr 10, 2018 · Event occurred Feb 8, 2018

Report 1221826-2018-00028 · MDR key 7418124

Device

Generic name

Flexible Video Cystoscope

Model number

11272VNU

Catalog number

11272VNU

Product problems

  • Contamination /Decontamination Problem
  • Contamination /Decontamination Problem

Patient

75 YR

  • Bacterial Infection
  • Bacterial Infection

Narrative

Additional Manufacturer Narrative

THE PRODUCT EVALUATION CONCLUDED THE FOLLOWING: THERE IS DEBRIS ON DISTAL LENS AND DISTAL TIP OF THE SCOPE, ANGLE COVER IS CRACKED AND HAS DEBRIS ON IT. THE SHAFT MARKER RINGS ARE DISCOLORED. A NICK WAS FOUND ON THE HANDLE HOUSING. THE EVALUATION RESULTS SUGGEST THAT USER ERROR CAN BE LINKED TO THE PHYSICAL CONDITION OF THE INSTRUMENT. INVESTIGATION STILL IN PROGRESS.

Description of Event or Problem

ALLEGEDLY, THE PHYSICIAN PERFORMED A CYSTOSCOPY PROCEDURE ON PATIENT. PATIENT'S URINE WAS CULTURED AND PSEUDOMONAS AERUGINOSA INFECTION WAS CONFIRMED FROM THE LAB RESULTS. PATIENT WAS TREATED WITH ANTIBIOTICS FROM A DOCTOR OUTSIDE OF THE CLINIC. THE DOCTOR REPORTED THAT PATIENT IS DOING FINE.

Additional Manufacturer Narrative

THE PRODUCT EVALUATION CONCLUDED THE FOLLOWING: THERE IS DEBRIS ON DISTAL LENS AND DISTAL TIP OF THE SCOPE, ANGLE COVER IS CRACKED AND HAS DEBRIS ON IT. THE SHAFT MARKER RINGS ARE DISCOLORED. A NICK WAS FOUND ON THE HANDLE HOUSING. THE EVALUATION RESULTS SUGGEST THAT USER ERROR CAN BE LINKED TO THE PHYSICAL CONDITION OF THE INSTRUMENT. THE PHYSICAL EVALUATION OF THE FLEXIBLE VIDEO CYSTOSCOPE FOCUSED ON SCOPE DAMAGE AND WHETHER IT COULD HAVE AN IMPACT ON PATIENT INFECTIONS. THE PRESENCE OF DEBRIS CAN HARBOR ORGANISMS THAT CAN LEAD TO CROSS CONTAMINATION BETWEEN PATIENTS. DAMAGE SUCH AS SCRAPES IN THE CHANNEL CAN CONTRIBUTE TO INFECTIONS; THE DAMAGED AREA CAN HARBOR ORGANISMS THAT REDUCE THE EFFICACY OF CLEANING AND SUBSEQUENT REPROCESSING STEPS. IN ORDER TO PERFORM A MICROBIOLOGICAL ASSESSMENT OF THE VIDEO CYSTO URETHROSCOPE (11272VNU, S/N (B)(4)), ENDOSCOPE CHANNEL SAMPLING WAS PERFORMED AT OUR IN-HOUSE LABORATORY AND THE RESULTANT EXTRACT WAS SUBMITTED FOR MICROBIAL ANALYSIS ON APRIL 6, 2018. MULTIPLE LOCATONS AT THE CUSTOMER SITE WERE SAMPLED IN ORDER TO HELP DETERMINE THE SOURCE OF THE CAUSATIVE ORGANISM; STERILE GLOVES, TUBES, SAMPLE CONTAINERS, AND WATER FOR IRRIGATION WERE USED. THE SAMPLES WERE SUBMITTED TO NELSON LABORATORIES TO SPECIFICALLY DETERMINE IF P. AERUGINOSA WAS PRESENT. THE FINAL RESULTS CONFIRM THAT THE CAUSATIVE ORGANISM (P. AERUGINOSA) WAS NOT PRESENT IN THE SAMPLES ANALYZED. THE INVESTIGATION REFLECTS THERE IS NO DIRECT LINK BETWEEN THE SCOPE USE/REPROCESSING AND THE PATIENT INFECTIONS AS THE CAUSATIVE ORGANISM WAS NOT RECOVERED FROM ANY SAMPLE LOCATION.