ICHEM VELOCITY AUTOMATED URINE CHEMISTRY SYSTEM
Received Dec 1, 2018 · Event occurred Mar 31, 2019
Report 1061932-2018-01049 · MDR key 8122592
Device
Generic name
Method, Enzymatic, Glucose (urinary, Non-quantitative)
Manufacturer
Beckman Coulter Ireland Inc.Catalog number
700-7177-001
Product problems
- Leak/Splash
- Leak/Splash
Patient
Not reported
- Exposure to Body Fluids
- No Patient Involvement
- Exposure to Body Fluids
- No Patient Involvement
Narrative
Additional Manufacturer Narrative
FOLLOW UP 02: MANUFACTURING SITE NAME AND ADDRESS UPDATED TO SHOW CORRECT INFORMATION. BEC INTERNAL IDENTIFIER - CASE(B)(4).
Additional Manufacturer Narrative
CLARIFICATION TO INITIAL REPORT: THE INITIAL REPORT STATED THAT THERE WAS ONE OPERATOR THAT HAD COME INTO CONTACT WITH A BIOHAZARDOUS LIQUID. UPON FURTHER REVIEW IT WAS FOUND TO BE TWO OPERATORS THAT WERE SPRAYED WITH THE LIQUID. PER FOLLOW UP WITH THE CUSTOMER ON 04 DECEMBER 2018, THERE WAS ONLY ONE OPERATOR THAT WAS CONFIRMED TO HAVE DIRECT EXPOSURE. THERE WERE SEVERAL ATTEMPTS MADE BY CUSTOMER TECHNICAL SPECIALIST (CTS) ON NOVEMBER 8, 2018, NOVEMBER 9TH 2018 AND NOVEMBER 15TH 2018 TO OBTAIN ADDITIONAL INFORMATION REGARDING THE SECOND END USER (THE CUSTOMER'S CO-WORKER) AND NO ADDITIONAL INFORMATION WAS PROVIDED. THE INFORMATION AVAILABLE IS NOT ENOUGH TO DETERMINE THE SEVERITY OF EXPOSURE TO THE SECOND OPERATOR. IT WAS CONFIRMED THAT THE LIQUID FROM THE DRAIN TUBING SPRAYED ONTO THE FIRST OPERATOR CAUSING THE LIQUID TO COME INTO DIRECT CONTACT WITH THE EYES, NOSE, MOUTH, CLOTHING AND HANDS. BEC INTERNAL IDENTIFIER - (B)(4).
Additional Manufacturer Narrative
THE FIELD SERVICE ENGINEER (FSE) ARRIVED TO THE CUSTOMER¿S SITE AND DETECTED THAT THE WASTE DRAIN TUBING WAS DISLODGED FROM THE DRAIN PORT. THE FSE REPLACED THE TUBING TO RESOLVE THE LEAK OF THE CUSTOMER'S ICHEMVELOCITY AUTOMATED URINE CHEMISTRY SYSTEM. THE WASTE DRAIN TUBING MAY CONTAIN CHEMICAL FLUIDS SUCH AS IWASH AND LAMINA. THE SAFETY DATA SHEETS (SDS) FOR THESE ITEMS INDICATE THAT THESE CHEMICAL FLUIDS ARE NOT CONSIDERED TO BE HAZARDOUS. THERE IS ALSO THE LIKELIHOOD THAT URINE WAS PRESENT AT THE TIME OF THE LEAK. THE LIQUID WAS REPORTED TO HAVE COME INTO DIRECT CONTACT WITH THE CUSTOMER¿S EYES, NOSE, MOUTH, CLOTHING AND HANDS, CONFIRMING THERE WAS EXPOSURE TO THE MUCOUS MEMBRANE WITH BIOHAZARDOUS MATERIAL. (B)(4).
Description of Event or Problem
THE CUSTOMER REPORTED THAT THE DRAIN HOSE (DRAIN TUBING) DISLODGED (POPPED-OFF) FROM THE RIGHT SIDE OF THEIR ICHEMVELOCITY AUTOMATED URINE CHEMISTRY SYSTEM AND SPRAYED APPROXIMATELY 20 MILLILITERS (ML) OF A PRESSURIZED FLUID WHICH THE CUSTOMER STATES WAS A CLEAR REAGENT AND WASTE MATERIAL. THE CUSTOMER NOTICED THAT THE DRAIN TUBING CONTINUED TO POP-OFF OF THEIR INSTRUMENT. WHEN THE DRAIN TUBING BECAME DISCONNECTED, THE CUSTOMER STATED THAT THERE WAS FLUID THAT SPRAYED FROM THE DRAIN TUBING. THE LIQUID FROM THE DRAIN TUBING WAS REPORTED TO HAVE SPRAYED ONTO THE CUSTOMER CAUSING THE LIQUID TO COME INTO DIRECT CONTACT WITH THE EYES, NOSE, MOUTH, CLOTHING AND HANDS. THE CUSTOMER TECHNICAL SUPPORT SPECIALIST (CTS) THERE WAS DIRECT EXPOSURE TO OPEN WOUNDS AND/OR MUCOUS MEMBRANES THAT RESULTED WITH THE CUSTOMER SEEKING MEDICAL ATTENTION. THE CUSTOMER DID HAVE PERSONAL PROTECTIVE EQUIPMENT (PPE) WHICH CONSISTED OF GLOVES, LABORATORY COAT AND EYE PROTECTION AT THE TIME OF THE EVENT. THERE WERE NO ERRONEOUS RESULTS THAT WERE GENERATED OR REPORTED OUTSIDE OF THE CUSTOMER¿S LABORATORY AS A RESULT OF THIS EVENT.