BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    SAFETY NEO-SERT UVC TRAY W/O C

    MDR report key: 11974143 · Received June 10, 2021

    Report

    Report Number
    3009211636-2021-00752
    Event Type
    Malfunction
    Date Received
    June 10, 2021
    Report Date
    August 9, 2021
    Product Code
    PXJ
    UDI-DI
    10884527005079
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TN, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 0

    SECTION D2: PRODUCT CODE UPDATED FROM FOS CATHETER, UMBILICAL ARTERY TO PXJ UMBILICAL CATHETER INSERTION TRAY.

    Additional Manufacturer Narrative · 0

    INVESTIGATION SUMMARY: THE PRODUCT REPORTED IS A UVC INSERTION TRAY WHICH PROVIDES THE COMPONENTS NEEDED FOR CONDUCTING A CATHETER INSERTION PROCEDURE. ONE OF THE COMPONENTS INCLUDED IN THIS KIT IS A SAFETY SCALPEL WHICH IS PROVIDED BY AN EXTERNAL SUPPLIER. THE SCALPEL HAS 3 DIFFERENT POSITIONS: OPEN, CLOSE AND LOCKED. ONCE LOCKED, AND FOR SAFETY REASONS AS THE NAME INDICATES, IT CANNOT BE RE-OPENED. THIS LOCKING FEATURE WAS IMPLEMENTED TO MEET OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) REQUIREMENTS TO PREVENT SHARPS INJURIES. IN ORDER TO INITIALLY OPEN THE SCALPEL, FORCE NEEDS TO BE APPLIED TOWARDS THE OPEN SIGN. IF THE SECURITY LID IS MOVED TOWARDS THE BLADE (UPWARDS), THE LID WILL LOCK AND THE SCALPEL CANNOT BE USED. A LOT NUMBER WAS NOT PROVIDED FOR THIS INCIDENT THEREFORE A MANUFACTURING DEVICE HISTORY REVIEW (DHR) OR PRODUCT/PROCESS CHANGES REVIEW COULD NOT BE PERFORMED. HOWEVER, ALL DHRS ARE REVIEWED FOR ACCURACY PRIOR TO PRODUCT RELEASE. THE ACTUAL SAMPLE INVOLVED IN THE REPORTED INCIDENT WAS NOT RETURNED FOR EVALUATION. NO ADDITIONAL INFORMATION, PICTURES, OR VIDEOS WERE RECEIVED. CONSEQUENTLY, IT WAS NOT POSSIBLE TO EVALUATE THE INCIDENT DEVICE AS PART OF A COMPREHENSIVE FAILURE INVESTIGATION AND THE EXACT ROOT CAUSE COULD NOT BE DETERMINED. PRELIMINARY EVALUATION SHOWS THAT THE REPORTED ISSUE IS POTENTIALLY RELATED TO INADVERTENTLY LOCKING THE SCALPEL DURING IMPROPER HANDLING OF THE PRODUCT. ADDITIONALLY, IT WAS FOUND THAT THE REPORTED UVC KIT DOES NOT INCLUDE INSTRUCTIONS FOR USE (IFU) FOR THE SCALPEL. BASED ON A MEDICAL SAFETY ASSESSMENT, NOT INCLUDING THE IFU INFORMATION FOR THE SAFETY SCALPEL PREVENTS CLINICIANS FROM BEING MADE AWARE OF THE PERMANENT LOCKING FEATURE OF THIS SAFETY SCALPEL WHICH CAN CREATE A DELAY TO TREATMENT/THERAPY AND MAY CONTRIBUTE TO PATIENT/USER HARM. AS PART OF CONTINUOUS IMPROVEMENTS, A CORRECTIVE AND PREVENTATIVE ACTION (CAPA) HAS BEEN OPENED. AN IFU FOR THE SAFETY SCALPEL WILL BE CREATED AND INCORPORATED INTO THE UVC KIT TRAY PN 43201. THE CAPA WILL ALSO DETERMINE IF ANY ADDITIONAL ACTIONS ARE NEEDED TO PREVENT THE REOCCURRENCE OF THE REPORTED CONDITION.

    Description of Event or Problem · 0

    THE CUSTOMER REPORTED THAT THE #11 SAFETY SCALPEL IS ALWAYS DIFFICULT TO DISENGAGE AND THEY HAVE REPORTED A USER CUTTING THEIR FINGERS WHEN ATTEMPTING TO DISENGAGE THE SAFETY DEVICE.

    Additional Manufacturer Narrative · 1

    THE INCIDENT SAMPLE HAS BEEN REQUESTED BUT TO DATE HAS NOT BEEN RECEIVED FOR EVALUATION. IF THE SAMPLE IS RECEIVED, OR IF ADDITIONAL INFORMATION PERTINENT TO THE INCIDENT IS OBTAINED A FOLLOW-UP REPORT WILL BE SUBMITTED. AS PART OF OUR MANUFACTURING PROCESS, ALL DEVICE HISTORY RECORDS ARE REVIEWED AND APPROVED BY QUALITY, PRIOR TO RELEASE OF PRODUCT.

    Description of Event or Problem · 1

    CUSTOMER REPORTED THEY USE THIS TRAY AND THE SAFETY DEVICE IS ALWAYS DIFFICULT TO DISENGAGE AND THEY HAVE REPORTED A USER CUTTING THEIR FINGER WHEN ATTEMPTING TO DISENGAGE THE SAFETY DEVICE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    868897 SAFETY NEO-SERT UVC TRAY W/O C UMBILICAL CATHETER INSERTION TRAY PXJ 43201 UNKNOWN 10884527005079
    868898 SAFETY NEO-SERT UVC TRAY W/O C UMBILICAL CATHETER INSERTION TRAY PXJ 43201 UNKNOWN 10884527005079

    Patients

    Seq Age Sex Outcome Treatment
    1