FDA Adverse Event Malfunction Summary report: N

BD PHOENIX¿ AST BROTH, 4.5 ML

MDR report key: 16060825 · Received December 28, 2022

Report

Report Number
1119779-2022-01533
Event Type
Malfunction
Date Received
December 28, 2022
Date of Event
December 13, 2022
Report Date
January 30, 2023
Manufacturer
BECTON, DICKINSON & CO. (SPARKS)
Product Code
LON
PMA / PMN Number
K020321
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CA
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

THIS COMPLAINT IS CONFIRMED. THIS COMPLAINT IS FOR CONTAMINATION AND LOW FILL OF PHOENIX AST BROTH TUBE (246011) BATCH 2181667. ONE TUBE FROM THE PHOTO WAS EMPTY, AND ANOTHER WAS CLOUDY. BASED OFF THE PHOTO, THIS COMPLAINT IS CONFIRMED. A REVIEW OF QUALITY NOTIFICATIONS REVIEWED NO QUALITY NOTIFICATIONS GENERATED ON THE COMPLAINT BATCH. A REVIEW OF COMPLAINTS REVEALED NO OTHER COMPLAINTS ON THIS BATCH. COMPLAINT TRENDING WAS PERFORMED AND THERE ARE NO TRENDS ASSOCIATED WITH THIS DEFECT. BD ID/AST WILL CONTINUE TO MONITOR FOR TRENDS ASSOCIATED WITH THIS DEFECT AND TAKE ACTION AS NECESSARY. 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.

Additional Manufacturer Narrative · 0

COMMON DEVICE NAME: SYSTEM, TEST, AUTOMATED ANTIMICROBIAL SUSCEPTIBILITY, SHORT INCUBATION. A DEVICE EVALUATION IS ANTICIPATED, BUT HAS NOT YET BEGUN. UPON COMPLETION OF THE INVESTIGATION, A SUPPLEMENTAL REPORT WILL BE FILED.

Description of Event or Problem · 0

IT WAS REPORTED THAT WHILE USING THE BD PHOENIX¿ AST BROTH, 4.5 ML THAT THERE WAS CONTAMINATION. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: THE CUSTOMER REPORTED TWO EMPTY TUBES AND ONE CONTAMINATED TUBE FROM LOT 2181667.

Description of Event or Problem · 0

IT WAS REPORTED THAT WHILE USING THE BD PHOENIX¿ AST BROTH, 4.5 ML THAT THERE WAS CONTAMINATION. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: THE CUSTOMER REPORTED TWO EMPTY TUBES AND ONE CONTAMINATED TUBE FROM LOT 2181667.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
2078480 BD PHOENIX¿ AST BROTH, 4.5 ML SEE H.10 LON BECTON, DICKINSON & CO. (SPARKS) 2181667

Patients

Seq Age Sex Outcome Treatment
1 Unknown