inforMED
InjuryKTN

HENRY SCHEIN MONO TEST DEVICE 20T

Received Mar 31, 2020

Report 2027969-2020-00017 · MDR key 9908585

Device

Generic name

Mononucleosis Reagent Test Kit

Manufacturer

Alere San Diego

Model number

IMO-402

Lot number

MON9062004

Product problems

  • Leak/Splash
  • Leak/Splash

Patient

Not reported

  • Exposure to Body Fluids
  • Exposure to Body Fluids

Narrative

Additional Manufacturer Narrative

RESULTS PENDING COMPLETION OF INVESTIGATION.

Description of Event or Problem

A LAB TECHNICIAN WAS INSERTING THE DISPENSING BULB ON A MONO TEST KIT WHEN THE CAPILLARY TUBE BROKE. AT THE TIME OF THE COMPLAINT, THE CUSTOMER REPORTED A POTENTIAL FOR EXPOSURE. THE USER WAS WEARING PPE DURING USE OF THE PRODUCT. ON (B)(6) 2020, IT WAS REPORTED THAT THE BLOOD DID GET ON THE FACE AND HAIR OF THE LAB TECHNICIAN. THE LAB TECHNICIAN WAS TESTED DUE TO POTENTIAL EXPOSURE TO A HAZARDOUS FLUID. NO INJURIES OCCURRED. ALTHOUGH REQUESTED, NO FURTHER INFORMATION WAS RECEIVED.

Additional Manufacturer Narrative

D4: LOT NUMBER, MON9062004. EXPIRATION DATE, 5/26/2021. UDI, (B)(4). D10: DEVICE RETURNED TO MANUFACTURER, 04/24/2020. G4: DATE OF THE INVESTIGATION CONCLUSION, 05/04/2020. H3: YES. INVESTIGATION CONCLUSION: CAPILLARY TUBES FROM RETAINED AND RETURNED KITS FROM THE REPORTED LOT NUMBER WERE VISUALLY INSPECTED AND NO ABNORMALITIES WERE OBSERVED. ALL CAPILLARY TUBES MET THE SPECIFICATION FOR OUTER DIAMETER. THE CAPILLARY TUBES WERE USED TO COLLECT AND DISPENSE FINGERSTICK WHOLE BLOOD SAMPLES, AND THE REPORTED ISSUE WAS NOT REPLICATED. THE CASE DETAILS WERE REVIEWED ALONG WITH THE COMPLAINT HISTORY FOR THE REPORTED ISSUE AND NO INDICATIONS OF A SYSTEMIC ISSUE WERE IDENTIFIED. MANUFACTURING BATCH RECORD REVIEW DID NOT UNCOVER ANY RELEVANT NON-CONFORMANCES AND FOUND THAT THE LOT MET QUALITY CONTROL SPECIFICATIONS. THE RISK OF POTENTIAL HARM TO THE USER FROM A BROKEN CAPILLARY TUBE WAS ASSESSED. THE SEVERITY RATING IS MARGINAL WITH A PROBABILITY OF OCCURRENCE RATING OF IMPROBABLE. THE RISK IS CONSIDERED TO BE REDUCED AS FAR AS POSSIBLE. A ROOT CAUSE COULD NOT BE DETERMINED FROM THE AVAILABLE INFORMATION AS THE REPORTED ISSUE WAS NOT REPLICATED DURING TESTING OF EITHER RETENTION OR RETURNED PRODUCT. COMPLAINTS ARE TRACKED AND TRENDED ON A MONTHLY BASIS. PER THE PACKAGE INSERT, WEAR PROTECTIVE CLOTHING SUCH AS LABORATORY COATS, DISPOSABLE GLOVES AND EYE PROTECTION WHEN SPECIMEN SAMPLES ARE ASSAYED.