Description of Event or Problem · 0
THIS IS A FYI ISSUE THAT ROSE FROM A THE JOINT COMMISSION (TJC) SURVEY FINDING. THE RECOMMENDATION RECEIVED FROM TJC IS TO FILE A REPORT WITH FDA AS NO RECALL HAS BEEN ISSUED AND THE PROBLEM IS NOT SPECIFIC TO ONE VENDOR. TJC BELIEVES THERE IS A PROBLEM WITH THE INTEGRITY OF THE MATERIAL BEING USED TO MANUFACTURE THE INSTRUMENTS. SITUATION: DISCOLORATION HAS BEEN FOUND IN THE THREADING OF THE MEDICAL DEVICE IN BOTH NEW AND USED GOMCOS. HISTORY: IN A PREVIOUS TJC SURVEY, IT WAS CITED DUE TO GOMCO CLAMPS BEING PRE-ASSEMBLED DURING THE STERILIZATION. THIS PROCESS DID NOT ALIGN WITH THE MEDICAL DEVICE IFU. ALL AFFECTED PARTIES HAVE BEEN MADE AWARE, AND THE PROCESS HAS BEEN UPDATED TO REFLECT DISASSEMBLY BEFORE STERILIZATION. BACKGROUND: DURING A RECENT INFECTION PREVENTION CONTROL ROUNDING, AN INFECTION CONTROL SPECIALIST OPENED A STERILE GOMCO AND USED AN ALCOHOL WIPE TO CLEAN THE DISCOLORED THREADING OF THE GOMCO. SOME REMNANTS WERE SMEARED ONTO THE WIPE. SPD (STERILE PROCESSING DEPARTMENT) WAS NOTIFIED, AND OUR TEAM WENT TO THE AREA AND PULLED ALL 1.1 AND 1.3 SIZE GOMCOS OUT OF CIRCULATION TO TREAT THEM WITH SURGISTAIN. SURGISTAIN: A SAFE CHEMICAL USED ON INSTRUMENTATION TO REMOVE RUST, STAIN, PITTING, HARD WATER, AND MINERAL DEPOSITS. SPD FOUND THAT THE DISCOLORATION IN THE THREADING WAS STILL APPARENT AFTER SURGISTAIN TREATMENT. SPD TOOK THE INSTRUMENT TO OUR 3RD PARTY INSTRUMENT REPAIR SPECIALIST FOR FURTHER INSIGHT. HE EXPLAINS THAT THE MATERIAL USED ON THE GOMCOS IS PLATED WITH CHROME, AND UNDERNEATH LIES BRASS. BRASS TARNISHES OVER TIME BECAUSE ITS METAL COMPONENTS ARE EXPOSED TO OXYGEN¿A NATURAL PROCESS. THIS PROCESS CAN TAKE A FEW DAYS TO A WEEK; HOWEVER, THE REPETITION OF SCREWING THE GOMCO KNUT ONTO THE THREADING SPEEDS UP OXIDATION. SPD REACHED OUT TO MEDLINE REQUESTING A CUSTOMER LETTER STATING THAT THE DISCOLORATION RESULTS FROM OXIDATION AND WILL NOT AFFECT PATIENT CARE. FILED PRODUCT COMPLAINTS WITH MEDLINE AND CONNECTED WITH VENDOR'S QA TEAM. CURRENTLY WAITING FOR REPLIES. ASSESSMENT: THE GOMCO IS A MEDICAL TWO DEVICE; HOWEVER, THE THREADING DOES NOT COME IN CONTACT WITH THE PATIENT SKIN. THE NEWBORN NURSERY AREA REPORTED NO PATIENT SAFETY ISSUES IN THE PAST. NO HISTORY OF A RECALL THROUGH MEDLINE. GOMCO PRODUCT INFORMATION: MEDLINE REF #: (B)(4).