COTTON-LEUNG BILIARY STENT
Report
- Report Number
- 3001845648-2018-00384
- Event Type
- Malfunction
- Date Received
- August 16, 2018
- Date of Event
- July 18, 2018
- Report Date
- September 13, 2018
- Manufacturer
- COOK IRELAND LTD
- Product Code
- FGE
- UDI-DI
- 00827002214699
- PMA / PMN Number
- K851962
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Occupation
- PHYSICIAN
Narratives
COOK IRELAND LTD (MANUFACTURER) IS SUBMITTING THIS REPORT ON BEHALF OF COOK MEDICAL INCORPORATED (CMI)(IMPORTER). EXEMPTION NUMBER: E2016031. INFORMATION PERTAINING TO SECTION G.1 AS FOLLOWS: IMPORTER SITE CONTACT AND ADDRESS: (B)(4) COOK MEDICAL INCORPORATED (CMI) 1025 ACUFF ROAD P.O BOX 4195 BLOOMINGTON INDIANA 47402-4195. IMPORTER SITE ESTABLISHMENT REGISTRATION NUMBER: 3005580113. INVESTIGATION IS STILL PENDING, A FOLLOW UP MDR WILL BE SUBMITTED TO INCLUDE THE INVESTIGATION CONCLUSIONS.
510(K) NUMBER: K851962. COOK IRELAND LTD (MANUFACTURER) IS SUBMITTING THIS REPORT ON BEHALF OF COOK MEDICAL INCORPORATED (CMI)(IMPORTER). EXEMPTION NUMBER: E2016031. INFORMATION PERTAINING (B)(4). IMPORTER SITE ESTABLISHMENT REGISTRATION NUMBER: (B)(4). THE CLSO-10-7 DEVICE OF LOT C1476463 INVOLVED IN THIS COMPLAINT WAS RETURNED FOR EVALUATION, OPENED BUT WITH THE ORIGINAL PACKAGING. WITH THE INFORMATION PROVIDED, A PHYSICAL EXAMINATION AND DOCUMENT BASED INVESTIGATION WAS CONDUCTED. THE DEVICE RELATED TO THIS OCCURRENCE UNDERWENT A LABORATORY EVALUATION ON THE 27AUG2018. IT SHOULD BE NOTED THAT THE CUSTOMER STATED IN ADDITIONAL INFORMATION THAT A 7 FRENCH PUSHING CATHETER (PC-7 WAS USED TO PUSH THE STENT, HOWEVER THE PC-7 IS NOT COMPATIBLE WITH THE CLSO-10-7 THEREFORE IT WOULD NOT BE ABLE TO PUSH THE STENT PASSED THE STRICTURE. THE COMPLAINT IS CONFIRMED AS USER ERROR BASED ON CUSTOMER TESTIMONY. THE RELEVANT COOK PRODUCT MANAGER HAS BEEN CONTACTED TO OFFER RETRAINING TO THE CUSTOMER INVOLVED IN THIS COMPLAINT, TO PREVENT FUTURE OCCURRENCE DOCUMENTS REVIEW: A REVIEW OF THE MANUFACTURING RECORDS FOR THE CLSO-10-7 OF LOT C1476463 DID NOT REVEAL ANY DISCREPANCIES THAT COULD HAVE CONTRIBUTED TO THIS COMPLAINT. UPON REVIEW OF THE COMPLAINTS HISTORY, THIS FAILURE HAS NOT OCCURRED PREVIOUSLY WITH THIS LOT. PRIOR TO DISTRIBUTION, ALL CLSO-10-7 DEVICES ARE SUBJECT TO VISUAL INSPECTION AND FUNCTIONAL CHECKS TO ENSURE DEVICE INTEGRITY. THERE IS ALSO A VISUAL INSPECTION OF THE PRODUCT AND PACKAGING AT PACKAGING, PACKAGING QC, AND POST STERILE QC. IT SHOULD BE NOTED THAT THIS COMPLAINT IS NOT RELATED TO A DEVICE MALFUNCTION, THIS COMPLAINT IS RELATED TO USER ERROR. IFU REVIEW: IT SHOULD BE NOTED THAT AS PER THE INSTRUCTIONS FOR USE (IFU0045-6) PRECAUTIONS SECTION THE USER IS INSTRUCTED TO "SELECT THE COOK INTRODUCER SYSTEM(IF NOT INCLUDED) IN THE APPROPRIATE FRENCH SIZE" AND IN THE CONTRAINDICATIONS SECTION THE USER IS ADVISED THAT "AN INABILITY TO PASS WIRE OR STENT THROUGH THE OBSTRUCTED AREA" IS CONTRAINDICATED. ROOT CAUSE: A POSSIBLE ROOT CAUSE OF USER ERROR AS PER THE EVIDENCE RECEIVED IN THE CUSTOMER ADDITIONAL INFORMATION. THE CUSTOMER STATED IN ADDITIONAL INFORMATION RECEIVED THAT A 7 FRENCH SIZED PUSHING CATHETER WAS USED TO PUSH THE 10 FRENCH SIZED STENT, HOWEVER THESE DEVICES ARE NOT COMPATIBLE THEREFORE IT WAS NOT POSSIBLE TO PUSH THE STENT. THE PRODUCT MANAGER HAS BEEN CONTACTED TO OFFER RETRAINING TO THE CUSTOMER TO PREVENT FURTHER OCCURRENCE. SUMMARY THE COMPLAINT IS CONFIRMED AS USER ERROR BASED ON CUSTOMER TESTIMONY. THE RISK WAS DETERMINED TO BE NO RISK (CATEGORY III). ACCORDING TO THE INITIAL REPORTER, THE PATIENT DID NOT EXPERIENCE ANY ADVERSE EFFECTS DUE TO THIS OCCURRENCE.
510(K) NUMBER: K851962. COOK IRELAND LTD (MANUFACTURER) IS SUBMITTING THIS REPORT ON BEHALF OF COOK MEDICAL INCORPORATED (CMI)(IMPORTER). EXEMPTION NUMBER: E2016031. IMPORTER SITE CONTACT AND ADDRESS: (B)(6). COOK MEDICAL INCORPORATED (CMI) (B)(4). IMPORTER SITE ESTABLISHMENT REGISTRATION NUMBER: (B)(4). INVESTIGATION IS STILL PENDING. A FOLLOW UP MDR WILL BE SUBMITTED TO INCLUDE THE INVESTIGATION CONCLUSIONS.
THIS COMPLAINT IS BEING REPORTED ON THE FDA MDR MALFUNCTION PRECEDENCE "DIFFICULT ADVANCEMENT". THEY TRIED TO PUT THE STENT IN THE BILE DUCT, BUT THE STENT COULD NOT PASS THROUGH THE STRICTURE IN THE BILE DUCT.
THIS FILE IS BEING REPORTED UNDER THE FDA MDR MALFUNCTION PRECEDENCE "DIFFICULT ADVANCEMENT." THEY TRIED TO PUT THE STENT IN THE BILE DUCT, BUT THE STENT COULD NOT PASS THROUGH THE STRICTURE IN THE BILE DUCT.
THEY TRIED TO PUT THE STENT IN THE BILE DUCT, BUT THE STENT COULD NOT PASS THROUGH THE STRICTURE IN THE BILE DUCT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 629798 | COTTON-LEUNG BILIARY STENT | FGE CATHETER, BILIARY, DIAGNOSTIC | FGE | COOK IRELAND LTD | G21469 | C1476463 | 00827002214699 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 44 YR |