BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    L3O0200 - NATURA

    MDR report key: 11342048 · Received February 18, 2021

    Report

    Report Number
    9618003-2021-00252
    Event Type
    Malfunction
    Date Received
    February 18, 2021
    Report Date
    January 27, 2021
    Manufacturer
    CONVATEC DOMINICAN REPUBLIC INC
    Product Code
    EXE
    PMA / PMN Number
    EXEMPT
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 0

    CORRECTION (G1) - CONTACT OFFICE ADDRESS: (B)(6). BATCH RECORD REVIEW RESULTS: LOT 0K01577 WAS MANUFACTURED ON 10/23/2020 IN THE CONVEX TWO PIECE (WCT) MANUFACTURING LINE, WITH A TOTAL OF 2304 MARKET UNITS. ON 21/JUN/2021, COMPLIANCE ENGINEER ID 6053 PERFORMED A BATCH RECORD REVIEW, TO VERIFY IF ALL THE APPLICABLE PROCEDURES WERE FOLLOWED AND NO ISSUES WERE FOUND; ALL THE COMPONENTS FOR ASSEMBLY WERE CORRECT PER BOM, UNDER SAP MATERIAL 1161267 AND MANUFACTURING ORDER 1552235. NO ISSUES RELATED TO THE DEFECT WERE FOUND IN THE DOCUMENTATION. IN ADDITION, THE BATCH RECORD OF BULK LOT 0K01576, MANUFACTURED IN THE CONVEX TWO PIECE (WCT) MANUFACTURING LINE, WAS REVIEWED AND NO ISSUES WERE FOUND; THE LOTS RAN ACCORDING TO SAP MATERIAL 1047902 AND ALL THE TESTING RESULTS WERE FOUND SATISFACTORY; THE PROCESS CARRIED OUT WAS FOUND ACCORDING TO AND PI21-139. NO ISSUES REGARDING THE FAILURE MODE REPORTED WAS FOUND IN THE DOCUMENTATION. BATCH RECORD REVIEW SUPPORTS THAT NO ISSUES REGARDING THE FAILURE MODE REPORTED WERE IDENTIFIED. RETURNED SAMPLE EVALUATION: A PHOTO WAS RECEIVED FROM CUSTOMER, HOWEVER, BASED ON VISUAL INSPECTION OF THE PHOTOGRAPH PROVIDED, THE REPORTED CONDITION CANNOT BE OBSERVED. NO UNUSED RETURN SAMPLE WAS RECEIVED FOR EVALUATION. INVESTIGATION CONCLUSION THE PURPOSE OF THIS INVESTIGATION WAS TO DETERMINE THE ROOT CAUSE ASSOCIATED INVESTIGATION WAFER DISC DECENTRALIZED, COMPLAINT MALFUNCTION CODES OST-PMC1.8 / 1.18 (SKIN BARRIER STARTER HOLE IS DEFECTIVE, MISALIGNMENT OR OFF CENTER, LEAKAGE MAY OCCUR), FOR LOTS MANUFACTURED IN CONVEX 2 PC AWC FACILITIES, HAINA D.R. THE HIGHEST SEVERITY RATING REPORTED WAS 4 WHICH IS CONSIDERED SERIOUS. ALSO, THE RISK LEVEL BASED ON THE INDIVIDUAL RISK ACCEPTABILITY CRITERIA AND RISK EVALUATION ABOVE IS MEDIUM, MEANING THAT THESE RISKS MAY BE ACCEPTED BUT FURTHER RISK CONTROL MEASURES SHALL BE CONSIDERED IF THEY ARE FEASIBLE AND WILL REDUCE THE RISK FURTHER. RISKS JUDGED MODERATE ARE CONSIDERED ACCEPTABLE BASED ON AN ACCEPTABLE RISK-BENEFIT PROFILE AND MUST BE ASSESSED FOR THE NEED FOR POST MARKET SURVEILLANCE. AFTER UNDERSTANDING THE PROCESS, A BRAINSTORMING TOOL WAS USED TO DETERMINE ALL THE POSSIBLE CAUSES OF THE PROBLEM; THE CAUSE & EFFECT DIAGRAM WAS USED AND AS A RESULT THERE WERE FOUND SEVEN (7) POTENTIAL CAUSES IDENTIFIED. ONE (1) OF THEM WERE DISCARDED, AND SIX (6) WERE CONFIRMED AND RETAINED AS ROOT/PROBABLE CAUSE FOR THE FAILURE. BASED ON THE INVESTIGATION FINDINGS, THE ROOT CAUSES FOR WAFER DECENTRALIZED WERE IDENTIFIED AS MANPOWER, METHOD AND MACHINE, SEE THE TABLE BELOW FOR DETAILS: PROBABLE ROOT CAUSE MANPOWER 1 PROCEDURE PI21-139 (CONVEX 2PC WAFER SUB ASSEMBLY MACHINE 2, SECTION 7.1.13 ¿ 7.1.14) NOT FOLLOWED BY MANUFACTURING PERSONNEL WHILE PLACING THE MASS ON LOADING PINS. 2 MANUFACTURING INSPECTIONS FAILED TO BE EXECUTED AS PER TM-017 AND MR21-139. MACHINE 3 PISTONS DEFECTIVE. 4 BASE THREAD OF K TOOL LOADING PIN DEFECTIVE. 5 ELECTRO-VALVE DAMAGED METHOD 6 MANUFACTURING INSPECTIONS FAILED TO BE EXECUTED AS PER TM-017 AND MR21-139. THE CAPA PLAN TW# 1461582 WAS GENERATED TO COVER THE PROBABLE CAUSES, TAKING APPROPRIATE ACTIONS AND MEASURE ITS EFFECTIVENESS. TO DATE NO ADDITIONAL INFORMATION HAS BEEN RECEIVED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED. FDA REGISTRATION NUMBER REPORTING SITE: 1049092 MANUFACTURING SITE: 9618003.

    Description of Event or Problem · 0

    TO DATE NO ADDITIONAL PATIENT OR EVENT DETAILS HAVE BEEN RECEIVED.

    Additional Manufacturer Narrative · 1

    DEVICE 5 OF 10. BASED ON THE AVAILABLE INFORMATION, THIS EVENT IS DEEMED TO BE A REPORTABLE MALFUNCTION. TO DATE NO ADDITIONAL INFORMATION HAS BEEN RECEIVED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED. (B)(4).

    Description of Event or Problem · 1

    THE END USER OPENED A NEW BOX OF WAFERS AND FOUND IT TO BE DEFECTIVE AS THE HOLE THAT WAS SUPPOSED TO BE IN THE MIDDLE WAS SKEWED TO ONE SIDE. THE WAFERS WERE PROBLEMATIC AS IN ORDER TO USE THEM ALL, SHE HAD TO REINFORCE THEM WITH HYTAPE ON ALL FOUR SIDES.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    240810 L3O0200 - NATURA PROTECTOR, OSTOMY EXE CONVATEC DOMINICAN REPUBLIC INC 413178 0K01577

    Patients

    Seq Age Sex Outcome Treatment
    1