FDA Adverse Event Malfunction Summary report: N

BD BBL¿ THIOGLYCOLLATE MEDIUM WITHOUT INDICATOR

MDR report key: 16948970 · Received May 17, 2023

Report

Report Number
1119779-2023-00571
Event Type
Malfunction
Date Received
May 17, 2023
Date of Event
May 2, 2023
Report Date
June 16, 2023
Manufacturer
BECTON, DICKINSON & CO. (SPARKS)
Product Code
JSG
UDI-DI
30382902212004
PMA / PMN Number
PREAMENDMENT
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
LA, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

A DEVICE EVALUATION AND/OR DEVICE HISTORY REVIEW IS ANTICIPATED BUT IS NOT COMPLETE. UPON COMPLETION, A SUPPLEMENTAL REPORT WILL BE FILED.

Additional Manufacturer Narrative · 0

H.6. INVESTIGATION SUMMARY: MATERIAL 221200 IS MANUFACTURED BY REHYDRATING THE MEDIA COMPONENTS WITH USP PURIFIED WATER, AND THOROUGHLY MIXING UNTIL A HOMOGENEOUS SOLUTION IS OBTAINED. THE TUBES ARE FILLED, CAPPED, TORQUED, AND THEN LABELED BY MACHINE PER STANDARD OPERATING PROCEDURE (SOP). THE TUBES ARE TERMINALLY AUTOCLAVED IN AN AIR OVER PRESSURE (AOP) AUTOCLAVE, PER MANUFACTURING INSTRUCTIONS, USING A VALIDATED CYCLE. POST AUTOCLAVING, TUBES ARE PACKAGED INTO FINAL SHIPPING CONFIGURATIONS. THE BATCH HISTORY RECORD REVIEW FOR BATCH 3060894 WAS SATISFACTORY AND NO QUALITY NOTIFICATIONS WERE GENERATED. FORMULATION, FILLING, TORQUING, AND AUTOCLAVING PROCESSES WERE WITHIN SPECIFICATIONS. QC INSPECTION AND TESTING WERE SATISFACTORY AT TIME OF RELEASE. AS PART OF THE RELEASE CRITERIA FOR THIS PRODUCT, THE BHR IS REVIEWED TO CONFIRM THE FOLLOWING: THE TOTAL ELAPSED TIME BETWEEN END OF FORMULATION AND START OF THE AUTOCLAVE CYCLE WAS WITHIN THE SPECIFIED LIMITS. ALL AUTOCLAVE PARAMETERS CONFORMED TO THE VALIDATED CYCLE PARAMETERS FOR THIS PRODUCT. THE MINIMUM F0 FOR THIS PRODUCT WAS MET. THE COMPLAINT HISTORY WAS REVIEWED, AND ONE OTHER COMPLAINT HAS BEEN TAKEN ON THIS BATCH. RETENTION SAMPLES FROM BATCH 3060894 (10 TUBES) WERE AVAILABLE FOR INSPECTION. NO MEDIA DEFECTS WERE OBSERVED IN 10/10 RETENTION SAMPLES. FOR FURTHER INVESTIGATION TWO UNINOCULATED RETENTION TUBES FROM BATCH 3060894 WERE PLACED INTO INCUBATION. ONE RETENTION TUBE WAS PLACED INTO 20-25-DEGREES CELSIUS INCUBATOR AND ONE RETENTION TUBE WAS PLACED INTO 33-37-DEGREES CELSIUS INCUBATOR FOR SEVEN DAYS. AT SEVEN DAYS INCUBATION, THERE WERE NO TRACES OF MICROBIAL GROWTH OR CHANGE IN THE MEDIA COLOR AND CLARITY IN THE 2/2 INCUBATED RETENTION TUBES. THE COLOR AND CLARITY OF THE MEDIA REMAINED LIGHT TO MEDIUM LIGHT YELLOW, TRACE HAZY TO CLEAR, AS DESCRIBED IN THE CERTIFICATE OF ANALYSIS. TWO PHOTOS WERE RECEIVED TO ASSIST WITH THE INVESTIGATION: THE FIRST PHOTO SHOWS THE MEDIA OF THREE PARTIAL TUBES, THE CAPS CANNOT BE SEEN IN THE PHOTO. THE MEDIA ON ALL THREE TUBES APPEARS LIGHT TO MEDIUM LIGHT-YELLOW TRACE HAZY TO CLEAR AS DESCRIBED IN THE CERTIFICATE OF ANALYSIS. THE SECOND PHOTO SHOWS ONE TUBE FROM BATCH 3060894. THE MEDIA IS LIGHT TO MEDIUM LIGHT-YELLOW TRACE HAZY TO CLEAR AS DESCRIBED IN THE CERTIFICATE OF ANALYSIS. RETURNS WERE ALSO RECEIVED TO ASSIST WITH THE INVESTIGATION. THREE TUBES FROM BATCH 3060894 WERE RECEIVED IN A FEDEX SHIPPING BAG INSIDE OF A CANISTER WITH STYROFOAM. THE MEDIA IN ALL THREE TUBES APPEARED LIGHT TO MEDIUM YELLOW TRACE HAZY TO CLEAR AS DESCRIBED IN THE CERTIFICATE OF ANALYSIS. FOR FURTHER INVESTIGATION ALL THREE TUBES WERE PLACED INTO INCUBATION AT 33-37-DEGREES CELSIUS. AT THE END OF A SEVEN-DAY INCUBATION PERIOD NO MICROBIAL GROWTH OR CHANGE IN THE MEDIA COLOR AND CLARITY WAS OBSERVED. A GRAM STAIN WAS PERFORMED ON ONE RETURNED TUBE AND NO ORGANISMS WERE RECOVERED. ONE TUBE WAS ALSO PLATED ON TSA 5% SHEEP BLOOD AGAR AND NO ORGANISMS WERE RECOVERED. THIS COMPLAINT CANNOT BE CONFIRMED.

Description of Event or Problem · 0

IT WAS REPORTED THAT BD BBL¿ THIOGLYCOLLATE MEDIUM WITHOUT INDICATOR CONTAINED NON VIABLE GNB THAT ARE EVIDENT ON GRAM STAIN. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: CUSTOMER IS REPORTING THAT ITEM 221200, LOT# 3060894 CONTAINS NON VIABLE GNB THAT ARE EVIDENT ON GRAM STAIN AND COULD BE REPORTED ON PATIENT SPECIMENS.

Description of Event or Problem · 0

IT WAS REPORTED THAT BD BBL¿ THIOGLYCOLLATE MEDIUM WITHOUT INDICATOR CONTAINED NON VIABLE GNB THAT ARE EVIDENT ON GRAM STAIN. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: CUSTOMER IS REPORTING THAT ITEM 221200, LOT# 3060894 CONTAINS NON VIABLE GNB THAT ARE EVIDENT ON GRAM STAIN AND COULD BE REPORTED ON PATIENT SPECIMENS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
584896 BD BBL¿ THIOGLYCOLLATE MEDIUM WITHOUT INDICATOR CULTURE MEDIA, NON-SELECTIVE AND NON-DIFFERENTIAL JSG BECTON, DICKINSON & CO. (SPARKS) 221200 3060894 30382902212004

Patients

Seq Age Sex Outcome Treatment
1 Unknown