FDA Adverse Event Malfunction Summary report: N

BD PHOENIX¿ AST BROTH

MDR report key: 15902593 · Received December 2, 2022

Report

Report Number
1119779-2022-01447
Event Type
Malfunction
Date Received
December 2, 2022
Date of Event
November 18, 2022
Report Date
January 26, 2023
Manufacturer
BECTON, DICKINSON & CO. (SPARKS)
Product Code
LON
UDI-DI
30382902460030
PMA / PMN Number
K020321
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
IN
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

H.6 INVESTIGATION SUMMARY THIS COMPLAINT IS NOT CONFIRMED. THIS COMPLAINT IS FOR FOREIGN MATERIAL RESEMBLING MOLD IN A TUBE OF PHOENIX AST BROTH (246003) BATCH NUMBER 2082249. THE CUSTOMER PROVIDED PHOTOS FOR INVESTIGATION, HOWEVER NO PRODUCT RETURNS. THE PHOTOS ILLUSTRATED A TUBE OF BROTH WITH DISCOLORATION RESEMBLING MOLD BUT NO BATCH NUMBER PRESENT. FOR FURTHER INVESTIGATION, RETENTION SAMPLES OF THE COMPLAINT BATCH WERE EVALUATED FOR CONTAMINATION, INVESTIGATION REVEALED THAT 0/100 TUBES HAD CONTAMINATION. AS A RESULT OF THIS INVESTIGATION, THIS COMPLAINT IS NOT CONFIRMED. A REVIEW OF QUALITY NOTIFICATIONS REVEALED NO QUALITY NOTIFICATIONS GENERATED ON THE COMPLAINT BATCH. A REVIEW OF COMPLAINTS WAS PERFORMED AND REVEALED ONE ADDITIONAL COMPLAINT ON THE COMPLAINT BATCH, WHICH IS RELATED TO THIS DEFECT. COMPLAINT TRENDING WAS PERFORMED AND NO TRENDS WERE IDENTIFIED ASSOCIATED WITH THIS DEFECT. A BD ID/AST PLANT QUALITY WILL CONTINUE TO MONITOR FOR TRENDS ASSOCIATED WITH THIS DEFECT. PLEASE CONTINUE TO COMMUNICATE ADDITIONAL CONCERNS. THE FOLLOWING ARE GUIDELINES TO HELP MINIMIZE PHOENIX AST ISSUES: MEDIA SELECTION ISOLATES MUST BE RECOVERED FROM NON-SELECTIVE MEDIA. SEE TABLE 16 RECOMMENDED MEDIA IN THE BD USER MANUAL FOR A LIST OF RECOMMENDED MEDIA. ENSURE QUALITY OF VENDOR SELECTION FOR PLATED MEDIA. VARIATIONS IN FORMULATIONS MAY IMPACT RESULTS. CULTURE HANDLING CULTURES MUST BE 18-24 HOURS OLD FOR GRAM-NEGATIVE & GRAM-POSITIVE ORGANISMS AND 18-48 HOURS OLD FOR YEAST ORGANISMS. FOR QC ORGANISMS, ENSURE ORGANISMS HAVE BEEN SUBCULTURED AT LEAST TWICE ON TWO CONSECUTIVE DAYS ON PROPER NONSELECTIVE MEDIA (GRAM-NEGATIVE OR GRAM-POSITIVE ORGANISMS: TSA WITH 5% SHEEP BLOOD, YEAST: SABOURAUD DEXTROSE AGAR). MCFARLAND PREPARATION USE OF A LOW-QUALITY STERILE COTTON SWAB, WHICH SHED FIBERS, COULD POTENTIALLY CONTRIBUTE TO A FALSELY HIGH MCFARLAND READING. POLYESTER SWABS ARE NOT RECOMMENDED. ENSURE BD APPROVED NEPHELOMETER IS ADEQUATELY CALIBRATED WITH NOT EXPIRED MCFARLAND CALIBRATION TUBES. PREPARED TUBES SHOULD BE VORTEXED FOR 5 SECONDS AND ALLOWED APPROXIMATELY 10 SECONDS FOR AIR BUBBLES TO SURFACE. ENSURE MCFARLAND FALLS WITHIN PROPER RANGE OF THE INOCULUM DENSITY. FOR 0.5 MCFARLAND SYSTEM, 0.50-0.60 IS ACCEPTABLE. FOR 0.25 MCFARLAND SYSTEM, 0.20-0.30 IS ACCEPTABLE. FOR YEAST PANELS, 2.00-2.40 IS ACCEPTABLE. CONFIRM CURRENT INSTRUMENT SETTINGS FOR INOCULUM DENSITY BEFORE INOCULATING PANELS. FOR EXAMPLE, ENSURE A 0.50 MCFARLAND WAS NOT PREPARED FOR A 0.25 INOCULUM DENSITY INSTRUMENT SETTING. USE BACTERIAL SUSPENSIONS WITHIN 60 MINUTES OF PREPARATION. PANEL PREPARATION PANELS SHOULD BE USED WITHIN 2 HOURS OF REMOVAL FROM POUCH. INOCULATE PANELS WITHIN 30 MINUTES OF THE TIME THAT THE AST BROTH INOCULUM IS PREPARED. ALLOW SUFFICIENT TIME FOR FLUID TO TRAVERSE DOWN THE WELL TRACKS BEFORE MOVING THE PANEL. AVOID TOUCHING THE FRONT AND BACKSIDE OF THE PANEL. HANDLE PANELS BY THE SIDES TO AVOID PRODUCING SMUDGES ON THE SURFACE OF THE PANELS. INOCULATED PANELS SHOULD BE HANDLED WITH CARE. AVOID KNOCKING OR JARRING THE PANEL. LOAD PANELS INTO INSTRUMENT WITHIN 30 MINUTES OF INOCULATION. THANK YOU AGAIN FOR CONTACTING BD AND PLEASE CONTINUE TO COMMUNICATE ANY FURTHER CONCERNS. H3 OTHER TEXT : SEE H.10

Additional Manufacturer Narrative · 0

INITIAL REPORTER ADDRESS: (B)(6). DEVICE EVALUATED BY MFR: A DEVICE EVALUATION AND/OR DEVICE HISTORY REVIEW IS ANTICIPATED BUT IS NOT COMPLETE. UPON COMPLETION, A SUPPLEMENTAL REPORT WILL BE FILED.

Description of Event or Problem · 0

IT WAS REPORTED THAT BD PHOENIX¿ AST BROTH CONTAMINATION OCCURRED. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: AS PER THE CUSTOMER MAIL AST BROTH FOR THE BD PHOENIX M50 WITH THE LOT NUMBER 2082249 WITH 100 VIALS RECEIVED WITH 10 % CONTAMINATED VIALS.

Description of Event or Problem · 0

IT WAS REPORTED THAT BD PHOENIX¿ AST BROTH CONTAMINATION OCCURRED. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: AS PER THE CUSTOMER MAIL AST BROTH FOR THE BD PHOENIX M50 WITH THE LOT NUMBER 2082249 WITH 100 VIALS RECEIVED WITH 10 % CONTAMINATED VIALS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
2329275 BD PHOENIX¿ AST BROTH SYSTEM, TEST, AUTOMATED ANTIMICROBIAL SUSCEPTIBILITY, SHORT INCUBATION LON BECTON, DICKINSON & CO. (SPARKS) 246003 2082249 30382902460030

Patients

Seq Age Sex Outcome Treatment
1 Unknown