FDA Adverse Event Other Summary report: N

ETCO2 DIVIDED SAMPLING CANNULA

MDR report key: 2913039 · Received January 8, 2013

Report

Report Number
2921601-2013-00001
Event Type
Other
Date Received
January 8, 2013
Date of Event
October 23, 2012
Report Date
January 8, 2013
Manufacturer
SALTER LABS
Product Code
CCK
PMA / PMN Number
K892406
Product Problem
Yes
Report Source
Manufacturer report
Reporter Occupation
RISK MANAGER

Narratives

Description of Event or Problem · 1

ON (B)(6) 2012, SALTER LABS VP RA/QA OBSERVED AN ADVERSE EVENT REPORTED VIA THE MAUDE DATABASE. ACCORDING TO THE MAUDE EVENT REPORT, THE 'INPUT OF THE O2 PORTION" OF A DIVIDED CANNULA "BECAME LOOSE AND FELL AWAY¿CAUSING THE [PATIENT] NOT TO BE HOOKED TO THE O2. NO HARM CAME TO THE [PATIENT], HOWEVER, THIS WAS A CONCERN". ADDITIONALLY, THE EVENT REPORT STATES THAT "[SALTER LABS] WAS CONTACTED TO NOTIFY COMPANY ABOUT THIS ISSUE;" HOWEVER, SALTER LABS HAS NO RECORD OF HAVING RECEIVED A COMPLAINT MATCHING THIS DESCRIPTION OR LOT NUMBER DESCRIBED IN THE EVENT. ONCE RECEIVING NOTIFICATION VIA MAUDE DATABASE, THIS COMPLAINT WAS FORMERLY ENTERED INTO THE COMPLAINT HANDLING SYSTEM. THE (B)(6) WAS CONTACTED TO CONFIRM IT IS NOT POSSIBLE TO DETERMINE THE CONTACT INFO FOR THE INITIAL REPORTING FACILITY. THE (B)(6) CONFIRMED INITIAL REPORTER INFO IS CONFIDENTIAL. RECORDS FOR THIS PAR NUMBER, LOT NUMBER, INDICATE THAT THE LOT OF PRODUCT IN QUESTION WENT TO A NUMBER OF CUSTOMERS AND AN EVEN LARGER NUMBER OF CUSTOMER LOCATIONS. THEREFORE, IT IS NOT POSSIBLE TO DETERMINE WHICH CUSTOMER/SUBSIDIARY CUSTOMER LIKELY FILED THE COMPLAINT AND ALSO NOT POSSIBLE TO DETERMINE THE PT STATUS OR WHETHER PRODUCT CAN BE RETURNED FOR EVALUATION. AS THE PRODUCT IN QUESTION HAS NOT BEEN RETURNED TO SALTER LABS FOR EVALUATION AND THERE IS NO ADD'L PRODUCT BELONGING TO THAT PART NUMBER, LOT NUMBER IN INVENTORY FOR SALTER LABS TO PERFORM AN EVAL, IT IS NOT POSSIBLE TO CONFIRM THE FAILURE AND/OR DETERMINE THE ROOT CAUSE OF THE FAILURE. THIS IS A FINAL REPORT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
10464 ETCO2 DIVIDED SAMPLING CANNULA SAMPLING CANNULA CCK SALTER LABS 4707F UNK

Patients

Seq Age Sex Outcome Treatment
1 UNK Other