BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BARD® GOODWIN SOUND

    MDR report key: 13625907 · Received February 28, 2022

    Report

    Report Number
    1018233-2022-00943
    Event Type
    Malfunction
    Date Received
    February 28, 2022
    Date of Event
    July 15, 2021
    Report Date
    February 17, 2022
    Manufacturer
    C.R. BARD, INC. (COVINGTON) -1018233
    Product Code
    FBX
    UDI-DI
    00801741047220
    PMA / PMN Number
    EXEMPT
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    KS, US
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THE REPORTED EVENT WAS CONFIRMED HOWEVER THE CAUSE WAS UNKNOWN. ONE SAMPLE WAS CONFIRMED TO EXHIBIT THE REPORTED FAILURE. THE DEVICE HAD NOT MET SPECIFICATIONS. AS THE DEVICE WAS NOT USED ON A PATIENT IT WAS NOT USED FOR DIAGNOSTIC OR TREATMENT PURPOSES. A POTENTIAL ROOT CAUSE FOR THIS FAILURE COULD BE "IMPROPER HIGH LEVEL DISINFECTION OR STERILIZATION". A POTENTIAL ROOT CAUSE FOR THIS FAILURE COULD BE "IMPROPER HIGH LEVEL DISINFECTION OR STERILIZATION". THE LOT NUMBER WAS UNKNOWN; THEREFORE, THE DEVICE HISTORY RECORD COULD NOT BE REVIEWED. THE INSTRUCTIONS FOR USE WERE FOUND ADEQUATE AND STATE THE FOLLOWING: "VISUAL INSPECTION EXAMINE EACH DEVICE FOR CLEANLINESS. IF VISIBLE SOIL REMAINS, REPEAT MANUAL CLEANING INSTRUCTIONS. VERIFY THAT DEVICES ARE FREE OF DEFORMATIONS (E.G. BENT, BROKEN, CORRODED, CRACKED, WORN, OR FRACTURED) THAT MAY IMPACT ITS INTENDED USE. DO NOT USE THE PRODUCT IF IT IS DAMAGED OR DEFECTIVE."

    Additional Manufacturer Narrative · 0

    THE REPORTED EVENT WAS CONFIRMED HOWEVER THE CAUSE WAS UNKNOWN. ONE SAMPLE WAS CONFIRMED TO EXHIBIT THE REPORTED FAILURE. THE DEVICE HAD NOT MET SPECIFICATIONS. AS THE DEVICE WAS NOT USED ON A PATIENT IT WAS NOT USED FOR DIAGNOSTIC OR TREATMENT PURPOSES. A POTENTIAL ROOT CAUSE FOR THIS FAILURE COULD BE "IMPROPER HIGH LEVEL DISINFECTION OR STERILIZATION". A POTENTIAL ROOT CAUSE FOR THIS FAILURE COULD BE "IMPROPER HIGH LEVEL DISINFECTION OR STERILIZATION". THE LOT NUMBER WAS UNKNOWN; THEREFORE, THE DEVICE HISTORY RECORD COULD NOT BE REVIEWED. THE INSTRUCTIONS FOR USE WERE FOUND ADEQUATE AND STATE THE FOLLOWING: "VISUAL INSPECTION EXAMINE EACH DEVICE FOR CLEANLINESS. IF VISIBLE SOIL REMAINS, REPEAT MANUAL CLEANING INSTRUCTIONS. VERIFY THAT DEVICES ARE FREE OF DEFORMATIONS (E.G. BENT, BROKEN, CORRODED, CRACKED, WORN, OR FRACTURED) THAT MAY IMPACT ITS INTENDED USE. DO NOT USE THE PRODUCT IF IT IS DAMAGED OR DEFECTIVE."

    Description of Event or Problem · 0

    IT WAS REPORTED THAT THE CUSTOMER RECEIVED A PARTIAL ORDER OF QUITE A FEW GOODWIN SOUND REPLACEMENTS AS IT HAD CONSISTENTLY HAD ISSUES WITH RUST 042822 AND 042820 AND DISCOLORATION 042816AND 042814 IN THE LUMEN. IT WAS ALSO STATED UPON RECEIVING THE NEW REPLACEMENTS, THEY WERE INSPECTED WITH A BORESCOPE AND DISCOLORATION WAS NOTED PRIOR TO ANY REPROCESSING. PER FOLLOW UP VIA EMAIL ON 16AUG21, THE LOT NUMBERS OF THE AFFECTED SOUNDS WHICH ARE MIXED WITH NEW BOX AND NEVER PROCESSED. THE NEW BOX, WHICH WAS PROCESSED INITIALLY, NEVER USED ON PATIENT. THIS WAS THE ONGOING ISSUE FOR THE CUSTOMER AND CONSISTENTLY REPLACING THESE. THE CUSTOMER CHECKED AND VERIFIED INTERNAL PROCESS AND FOLLOW THE IFU VERBATIM, FLUSHING WITH STERILE WATER AT POINT OF USE. THE BOX AND PACKAGING THAT CUSTOMER RECEIVED WAS FOR 11 SOUNDS. THEY HAVE TOTAL OF 24 SOUNDS 042824 AND 042826.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT THE CUSTOMER RECEIVED A PARTIAL ORDER OF QUITE A FEW GOODWIN SOUND REPLACEMENTS AS IT HAD CONSISTENTLY HAD ISSUES WITH RUST 042822 AND 042820 AND DISCOLORATION 042816AND 042814 IN THE LUMEN. IT WAS ALSO STATED UPON RECEIVING THE NEW REPLACEMENTS, THEY WERE INSPECTED WITH A BORESCOPE AND DISCOLORATION WAS NOTED PRIOR TO ANY REPROCESSING. PER FOLLOW UP VIA EMAIL ON 16AUG21, THE LOT NUMBERS OF THE AFFECTED SOUNDS WHICH ARE MIXED WITH NEW BOX AND NEVER PROCESSED. THE NEW BOX, WHICH WAS PROCESSED INITIALLY, NEVER USED ON PATIENT. THIS WAS THE ONGOING ISSUE FOR THE CUSTOMER AND CONSISTENTLY REPLACING THESE. THE CUSTOMER CHECKED AND VERIFIED INTERNAL PROCESS AND FOLLOW THE IFU VERBATIM, FLUSHING WITH STERILE WATER AT POINT OF USE. THE BOX AND PACKAGING THAT CUSTOMER RECEIVED WAS FOR 11 SOUNDS. THEY HAVE TOTAL OF 24 SOUNDS 042824 AND 042826.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    861463 BARD® GOODWIN SOUND GOODWIN SOUND FBX C.R. BARD, INC. (COVINGTON) -1018233 042812 UNK 00801741047220

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown Other