BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BD LUER-LOK STERILE, SINGLE USE SYRINGE

    MDR report key: 8311433 · Received February 6, 2019

    Report

    Report Number
    1213809-2019-00154
    Event Type
    Malfunction
    Date Received
    February 6, 2019
    Date of Event
    January 21, 2019
    Report Date
    April 24, 2019
    Manufacturer
    BECTON DICKINSON MEDICAL SYSTEMS
    Product Code
    FMF
    UDI-DI
    30382903096467
    PMA / PMN Number
    K980987
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    INVESTIGATION: FIVE 5ML LL SYRINGES IN FULLY SEALED BLISTER PACKS CONFIRMED TO BE FROM BATCH # 8267575 (P/N 309646) WERE RECEIVED AND EVALUATED. IT WAS OBSERVED THAT THERE WAS LOOSE GREENISH FOREIGN MATTER PRESENT IN EACH OF THE PACKAGES. THE FM APPEARS TO BE GREASE AND IS ON THE BARREL WALLS, THE FLANGE AND THE TIP WAS WELL AS ON THE WEBS ON THE PACKAGING. IN ALL CASES THE FM IS OUTSIDE THE FLUID PATH AND IS LARGER THAN LEVEL 3 IN SIZE IN WHICH IS REJECTABLE PER PRODUCT SPECIFICATION. THREE REPRESENTATIVE 5ML LL SYRINGES FROM BATCH 8267575, CATALOG # 309646 WITH VISUAL FOREIGN MATTER WERE TESTED FOR THE PRESENCE OF MOLD CONTAMINATION BY THE BD CANAAN MICROLAB. EACH SYRINGE WAS SWABBED UNDER ASEPTIC CONDITIONS. SWAB SAMPLES WERE TAKEN FROM THE LOCATION ON EACH SYRINGE WITH VISUAL CONTAMINATION AND STREAKED TO SABOURAUD DEXTROSE AGAR(SDA). SWAB SAMPLES WERE ALSO TAKEN FROM THE INSIDE BOTTOM WEB OF EACH SYRINGE PACKAGE WHERE VISUAL FOREIGN MATTER WAS PRESENT. THE SDA AGAR PLATES WERE INCUBATED IN THE INCUBATOR FOR 7 DAYS. SDA WAS SELECTED FOR USE DURING THIS INVESTIGATION BECAUSE IT IS COMMONLY USED FOR THE CULTIVATION OF YEAST AND MOLD. THE SDA AGAR PLATES WERE EXAMINED FOR GROWTH ON THE 7TH DAY OF INCUBATION. NO VISUAL EVIDENCE OF GROWTH WAS PRESENT ON ANY OF THE AGAR PLATES. SINCE NO EVIDENCE OF MOLD GROWTH WAS OBSERVED ON ANY OF THE AGAR PLATES, MOLD CONTAMINATION MAY BE RULED OUT AS THE CONTAMINANT OF THE THREE (3), BD 5ML LUER-LOKTM SYRINGES OF LOT#8267575, CATALOG # 309646 SAMPLED DURING THIS INVESTIGATION. FTIR TEST: USING FOURIER TRANSFORM INFRARED (FTIR) SPECTROSCOPY AND OPTICAL MICROSCOPY THIS STUDY AIMED TO IDENTIFY FOREIGN MATERIAL FOUND ON A 5ML LUER LOK SYRINGE (LOT# 8267575) WE RETRIEVED THE MATERIAL FROM THE BARREL SURFACE USING A TUNGSTEN NEEDLE THEN TRANSFERRED TO A SLIDE FOR FTIR SPECTROSCOPY. WE COLLECTED AN FTIR SPECTRUM AND BASED ON SPECTRAL LIBRARY SEARCHES WE CONCLUDE THE FM IS COMPOSED OF SILICONE CONTAINING HYDROCARBON LUBRICANT. PRODUCTION RECORDS FROM BATCH 8267575 SHOW THAT REPAIRS WERE MADE TO BOTTOM WEB CYLINDERS DURING THE TIME OF PRODUCTION. THE CYLINDERS ARE USED TO GUIDE THE BOTTOM WEB IN THE PACKAGING PROCESS. ADDITIONALLY, THE GREASE FOUND ON SYRINGES FROM BATCH 8267575 MATCHES WITH THE GREASE TYPE USED IN MACHINE PARTS AT PACKAGING TO PREVENT EXCESSIVE WEAR AND EQUIPMENT FAILURE. POTENTIAL ROOT CAUSE FOR THE FOREIGN MATTER DEFECT ¿GREASE¿ IS ASSOCIATED WITH THE PACKAGING PROCESS. GREASE IS USED TO LUBRICATE THE BEARINGS INSIDE THE CYLINDERS WHICH MAKE DIRECT CONTACT TO THE BOTTOM WEB. IT IS POSSIBLE THAT DURING THE REPAIR, THE OUTER PORTION OF THE CYLINDER WAS EXPOSED TO GREASE AND NOT CLEANED PROPERLY. THIS LED TO AN ISOLATED INCIDENT OF CONTAMINATED BOTTOM WEB THAT THEN CONTAMINATED THE OUTSIDE OF THE SYRINGE.

    Additional Manufacturer Narrative · 0

    CORRECTION: A MEDWATCH REPORT WAS RECEIVED VIA EMAIL. THE FOLLOWING INFORMATION HAS BEEN UPDATED: E.4. FDA NOTIFIED?: YES.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT 8 OF THE BD LUER-LOK¿ STERILE, SINGLE USE SYRINGES HAD MOLD DISCOVERED IN THEM BEFORE USE.

    Description of Event or Problem · 0

    IT WAS REPORTED THAT 8 OF THE BD LUER-LOK¿ STERILE, SINGLE USE SYRINGES HAD MOLD DISCOVERED IN THEM BEFORE USE.

    Additional Manufacturer Narrative · 1

    DATE OF EVENT: UNKNOWN. THE DATE RECEIVED BY MANUFACTURER HAS BEEN USED FOR THIS FIELD. 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 · 1

    IT WAS REPORTED THAT 8 OF THE BD LUER-LOK¿ STERILE, SINGLE USE SYRINGES HAD MOLD DISCOVERED IN THEM BEFORE USE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    103416 BD LUER-LOK STERILE, SINGLE USE SYRINGE PISTON SYRINGE FMF BECTON DICKINSON MEDICAL SYSTEMS 8267575 30382903096467

    Patients

    Seq Age Sex Outcome Treatment
    1 Other