FDA Adverse Event Malfunction Summary report: N

BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE

MDR report key: 15230321 · Received August 15, 2022

Report

Report Number
1911916-2022-00430
Event Type
Malfunction
Date Received
August 15, 2022
Date of Event
July 20, 2022
Report Date
October 24, 2022
Manufacturer
BD MEDICAL (BD WEST) MEDICAL SURGICAL
Product Code
NGT
PMA / PMN Number
NA
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CH
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

INVESTIGATION SUMMARY: IT WAS REPORTED THERE WERE SUSPECTED HAIR ITEMS IN THE SALINE. TO AID IN THE INVESTIGATION, ONE PHOTO WAS PROVIDED FOR EVALUATION BY OUR QUALITY TEAM. THE PHOTO SHOWS A SYRINGE WITH THE SYRINGE BARREL LABEL PARTIALLY LIFTED UP TO SHOW A BLACK STRING FOREIGN MATTER THAT APPEARS TO BE INSIDE THE SYRINGE. NO OTHER INFORMATION CAN BE OBTAINED FROM THE PHOTO. A DEVICE HISTORY RECORD REVIEW WAS COMPLETED FOR PROVIDED MATERIAL NUMBER: 306594, LOT NUMBER: 1202153. THE REVIEW DID NOT REVEAL ANY DETECTED QUALITY ISSUES DURING THE PRODUCTION OF THIS LOT THAT COULD HAVE CONTRIBUTED TO THE REPORTED DEFECT. TO DATE, THERE HAVE BEEN NO OTHER SIMILAR EVENTS REPORTED FOR THIS LOT. BASED ON THE INVESTIGATION AND WITH THE PHOTO SAMPLE ANALYSIS THE SYMPTOM REPORTED BY THE CUSTOMER IS CONFIRMED, BUT WITHOUT THE PHYSICAL SAMPLE ANALYSIS A PROBABLE ROOT CAUSE COULD NOT BE OFFERED.

Additional Manufacturer Narrative · 0

THE FOLLOWING FIELDS WERE UPDATED DUE TO ADDITIONAL INFORMATION: D.9. DEVICE AVAILABLE FOR EVAL?: YES. D.9. RETURNED TO MANUFACTURER ON: 03-OCT-2022. H.6. INVESTIGATION SUMMARY: IT WAS REPORTED THERE WERE SUSPECTED HAIR ITEMS IN THE SALINE. TO AID IN THE INVESTIGATION, ONE EMPTY SAMPLE WITH NO PACKAGING FLOW WRAP AND ONE PHOTO WAS PROVIDED FOR EVALUATION BY OUR QUALITY TEAM. A VISUAL INSPECTION WAS PERFORMED AND THERE IS A BLACK STRING AT THE BOTTOM OF THE SYRINGE BARREL. THE PHOTO SHOWS A SYRINGE WITH THE SYRINGE BARREL LABEL PARTIALLY LIFTED UP TO SHOW A BLACK STRING FOREIGN MATTER THAT APPEARS TO BE INSIDE THE SYRINGE. NO OTHER INFORMATION CAN BE OBTAINED FROM THE PHOTO. THE SAMPLE WAS SENT TO A LABORATORY TO ATTEMPT TO CONFIRM WHAT THE FOREIGN MATTER IS. THE FOREIGN MATTER APPEARED MORE RIGID AND THICKER THAN HUMAN HAIR. FOURIER-TRANSFORM INFRARED SPECTROSCOPY (FTIR) ANALYSIS WAS PERFORMED; HAIR WAS A 74% MATCH AND WHEAT GLUTEN FLOUR WAS AN 85% MATCH. NEITHER ONE OF THESE MATCHES ARE A HIGH ENOUGH PERCENTAGE TO MAKE A DEFINITE CONCLUSION AS TO THE COMPOSITION OF THE FOREIGN MATTER. A DEVICE HISTORY RECORD REVIEW WAS COMPLETED FOR PROVIDED MATERIAL NUMBER 306594, LOT NUMBER 1202153. THE REVIEW DID NOT REVEAL ANY DETECTED QUALITY ISSUES DURING THE PRODUCTION OF THIS LOT THAT COULD HAVE CONTRIBUTED TO THE REPORTED DEFECT. TO DATE, THERE HAVE BEEN NO OTHER SIMILAR EVENTS REPORTED FOR THIS LOT. BASED ON THE INVESTIGATION AND WITH THE RETURNED SAMPLE ANALYSIS THE SYMPTOM REPORTED BY THE CUSTOMER IS CONFIRMED, BUT THE PROBABLE SOURCE OF THE FOREIGN MATTER IS NOT KNOWN. COMPLAINTS RECEIVED FOR THIS DEVICE AND REPORTED CONDITION WILL CONTINUE TO BE TRACKED AND TRENDED. OUR QUALITY TEAM REGULARLY REVIEWS THE COLLECTED DATA FOR IDENTIFICATION OF EMERGING TRENDS.

Additional Manufacturer Narrative · 0

H6: INVESTIGATION SUMMARY: IT WAS REPORTED THERE WERE SUSPECTED HAIR ITEMS IN THE SALINE. TO AID IN THE INVESTIGATION, ONE PHOTO WAS PROVIDED FOR EVALUATION BY OUR QUALITY TEAM. THE PHOTO SHOWS A SYRINGE WITH THE SYRINGE BARREL LABEL PARTIALLY LIFTED UP TO SHOW A BLACK STRING FOREIGN MATTER THAT APPEARS TO BE INSIDE THE SYRINGE. NO OTHER INFORMATION CAN BE OBTAINED FROM THE PHOTO. A DEVICE HISTORY RECORD REVIEW WAS COMPLETED FOR PROVIDED MATERIAL NUMBER 306594, LOT NUMBER 1202153. THE REVIEW DID NOT REVEAL ANY DETECTED QUALITY ISSUES DURING THE PRODUCTION OF THIS LOT THAT COULD HAVE CONTRIBUTED TO THE REPORTED DEFECT. TO DATE, THERE HAVE BEEN NO OTHER SIMILAR EVENTS REPORTED FOR THIS LOT. BASED ON THE INVESTIGATION AND WITH THE PHOTO SAMPLE ANALYSIS THE SYMPTOM REPORTED BY THE CUSTOMER IS CONFIRMED, BUT WITHOUT THE PHYSICAL SAMPLE ANALYSIS A PROBABLE ROOT CAUSE COULD NOT BE OFFERED.

Additional Manufacturer Narrative · 0

CORRECTION: IMDRF ANNEX C GRID: C07.

Description of Event or Problem · 0

IT WAS REPORTED THAT FOREIGN MATTER WAS FOUND WITHIN THE BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER, TRANSLATED FROM CHINESE: "WHEN THE CUSTOMER USED THE FLUSH, HE FOUND THAT THERE WERE SUSPECTED HAIR ITEMS IN THE PHYSIOLOGICAL SALINE."

Description of Event or Problem · 0

IT WAS REPORTED THAT FOREIGN MATTER WAS FOUND WITHIN THE BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER, TRANSLATED FROM CHINESE: "WHEN THE CUSTOMER USED THE FLUSH, HE FOUND THAT THERE WERE SUSPECTED HAIR ITEMS IN THE PHYSIOLOGICAL SALINE."

Description of Event or Problem · 0

IT WAS REPORTED THAT FOREIGN MATTER WAS FOUND WITHIN THE BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER, TRANSLATED FROM CHINESE: "WHEN THE CUSTOMER USED THE FLUSH, HE FOUND THAT THERE WERE SUSPECTED HAIR ITEMS IN THE PHYSIOLOGICAL SALINE."

Description of Event or Problem · 0

IT WAS REPORTED THAT FOREIGN MATTER WAS FOUND WITHIN THE BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER, TRANSLATED FROM CHINESE: "WHEN THE CUSTOMER USED THE FLUSH, HE FOUND THAT THERE WERE SUSPECTED HAIR ITEMS IN THE PHYSIOLOGICAL SALINE."

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1238484 BD POSIFLUSH¿ PRE-FILLED SALINE SYRINGE SALINE VASCULAR ACCESS FLUSH NGT BD MEDICAL (BD WEST) MEDICAL SURGICAL 1202153

Patients

Seq Age Sex Outcome Treatment
1 Unknown