VITAL SIGNS HEAD POSITIONER
Received Feb 27, 2020 · Event occurred Jan 15, 2020
Report 9613793-2020-00007 · MDR key 9765619
Device
Generic name
Support, Patient Position
Manufacturer
Vyaire Medical.Model number
VITAL SIGNS¿ HEAD POSITIONERCatalog number
8000HDP
Lot number
49797348
Product problems
- Patient-Device Incompatibility
- Patient-Device Incompatibility
Patient
Not reported
- Burn(s)
- Burn(s)
Narrative
Additional Manufacturer Narrative
THE CUSTOMER REPORTED THAT THE PRODUCT SAMPLE AND PHOTO IS AVAILABLE FOR ANALYSIS. AT THIS TIME, VYAIRE HAS NOT RECEIVED THE SUSPECT DEVICE FOR EVALUATION. ANY ADDITIONAL INFORMATION RECEIVED FROM THE CUSTOMER WILL BE INCLUDED IN A FOLLOW-UP REPORT.
Description of Event or Problem
THE CUSTOMER REPORTED THAT THE PATIENT UNDERWENT SURGERY WHILE USING THE VITAL SIGNS¿ HEAD POSITIONER. AFTER THE LONG PROCEDURE, THE PATIENT WAS DISCOVERED TO HAVE BURNS AND ULCERS AROUND THE JAW.
Additional Manufacturer Narrative
DURING THE INVESTIGATION PROCESS, THE DEVICE HISTORY RECORD WAS REVIEWED FOR ANY DISCREPANCIES THAT MIGHT HAVE OCCURRED DURING PRODUCTION TO EXPLAIN THE ISSUE REPORTED, NOTHING WAS FOUND. SPECIFICATIONS PROVIDED TO DEROYAL WERE EXAMINED AND FOUND TO BE CORRECT AND CURRENT. THERE HAVE BEEN NO CHANGES TO THE PRODUCTION PROCESS OR THE RAW MATERIALS USED TO CONVERT THE FOAM POSITIONER. THE INSTRUCTIONS FOR US THAT ARE PLACED WITH THE PRODUCT STATE TO CONFIRM THE HEAD POSITIONER IS PROPERLY FITTED TO THE PATIENT'S FACE, ASSESSING FOR PRESSURE POINTS, AND TO PERIODICALLY REASSESS PATIENTS' POSITION IN THE PRODUCT FOR PRESSURE POINTS. DURING OUR INVESTIGATION, NOTHING WAS FOUND THAT WOULD INDICATE A MANUFACTURING ERROR OR DISCREPANCY THAT WOULD RESULT IN THE INJURIES REPORTED. IT SEEMS EVIDENT THAT THE PRESSURE ULCER OR SIMILAR INJURIES WERE CAUSED BY CLINICIANS NEGLIGENCE AS NO EVIDENCE HAS COME UP TO SHOW MALFUNCTION OF THE HEAD POSITIONER DEVICE.