inforMED
InjuryCCX

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.

Catalog 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.