IV SET AN120 W/O BP
Report
- Report Number
- 2243072-2019-00796
- Event Type
- Malfunction
- Date Received
- April 26, 2019
- Date of Event
- April 11, 2019
- Report Date
- June 7, 2019
- Manufacturer
- BECTON DICKINSON
- Product Code
- FPA
- PMA / PMN Number
- N/A
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- KS
- Reporter Occupation
- NURSE
Narratives
INVESTIGATION: ONE SAMPLE WAS RETURNED TO SBDM, LOT NUMBER IS 2811281. CLAMPING TEST UNDER NORMAL USING CONDITION: SBDM CONDUCT CLAMPING TEST UNDER NORMAL USING CONDITION FOR THE COMPLAINT SAMPLE, THE CLAMP COULD HOLD MEDICINE AND THERE WAS NO DRUG INFUSION. CLAMPING TEST UNDER HIGH AIR PRESSURE: SBDM CONDUCT CLAMPING TEST UNDER AIR PRESSURE(0.51MPA) FOR THE COMPLAINT SAMPLES, THE CLAMP COULD HOLD AIR AND THERE WAS NO AIR BUBBLE LEAKAGE. HOWEVER, SBDM FOUND LEAKAGE IN THE ANOTHER RECEIVED COMPLAINT SAMPLE OF (B)(4) WHICH WAS THE SAME COMPLAINT ISSUE. SBDM THUS CONDUCTED FURTHER INVESTIGATION ABOUT TUBE INNER & OUTER DIAMETER MEASUREMENT AND ECCENTRICITY OF ROLLER COMPONENT FOR COMPLAINT SAMPLE AND HOUSE SAMPLE. TUBE INNER & OUTER DIAMETER MEASUREMENT: USING PROFILE PROJECTOR, SBDM MEASURED THE INNER AND OUTER DIAMETER OF TUBE FOR BOTH COMPLAINT SAMPLE AND HOUSE SAMPLE, THE DIAMETER ARE WITHIN SPECIFICATION. ROLLER ECCENTRICITY TEST (UNIT: MM): USING VERNIER CALIPER, SBDM MEASURED THE LENGTH FROM CENTER TO EDGE OF ROLLER FOR BOTH RECEIVED COMPLAINT SAMPLE (CAVITY NO.: 5, MINIMUM LENGTH: 8.23. MAXIMUM LENGTH: 8.32) & HOUSE SAMPLE, CONCLUSION WAS THERE SEEMS TO BE ECCENTRICITY ISSUE IN THE ROLLER. HOUSE SAMPLE INSPECTION: SBDM INSPECTED 30 PCS FROM LOTS 2811211, 2811281 AND 2811301, NO ABNORMALITY WAS OBSERVED. SBDM ALSO MEASURED THE ROLLER CLAMP CONCENTRICITY, ALL 30 ROLLER CLAMPS WAS WITHIN SPECIFICATIONS. DEVICE HISTORY RECORD REVIEW: SBDM REVIEWED THE MANUFACTURING RECORD FOR LOT 2811281, NO ABNORMALITY WAS OBSERVED. ROOT CAUSE: FROM INVESTIGATIONS, SBDM CONDUCTED INSPECTION OF THE COMPLAINT SAMPLE & HOUSE SAMPLES FOR LEAKAGE TEST UNDER NORMAL CONDITION AND HIGH PRESSURE. NO LEAKAGE WAS OBSERVED ON THE RECEIVED COMPLAINT SAMPLE. SBDM ALSO CONDUCTED FURTHER TEST OF TUBE INNER & OUTER MEASUREMENT AND CHECK ECCENTRICITY OF ROLLER COMPONENT. THIS IS BECAUSE EVEN THERE WAS NO LEAKAGE IN THIS COMPLAINT SAMPLE, SBDM FOUND LEAKAGE ON SOME OF THE RECEIVED SAMPLE IN OTHER CASE (B)(4), PRODUCT: IV SET AN120 W/O BP. SBDM FOUND THERE WAS ECCENTRICITY IN THE ROLLER COMPONENT (THE LENGTH FROM CENTER TO EDGE OF ROLLER (MIN: 8.21MM, MAX: 8.4MM & GAP: 0.19MM) IN THE OTHER CASE ((B)(4)). SBDM THEN CHECKED ROLLER LENGTH FROM CENTER TO EDGE FOR 21 DIFFERENT LOT FROM RETENTION SAMPLES (TOTAL: 210EA) AND THE MAXIMUM GAP WAS 0.19 AND AVERAGE GAP WAS 0.09. IN CONCLUSION, SBDM ASSUMED THAT WHEN NARROW LOCATION OF THE ROLLER WHICH HAS ECCENTRICITY AND THE SMALLEST SIZE OF TUBE ARE MET WHEN ROLLER CLAMP IS IN LOCKED POSITION, MEDICINE LEAKAGE MIGHT OCCURRED INFREQUENTLY.
IT WAS REPORTED THAT DRUG WAS INFUSED AND LEAKED FROM THE IV SET AN120 W/O BP DURING USE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: "AFTER CLAMPING THE TUBE, DRUG WAS INFUSED".
(B)(4). DATE OF EVENT: UNKNOWN. A DEVICE EVALUATION IS ANTICIPATED, BUT HAS NOT YET BEGUN. UPON COMPLETION OF THE INVESTIGATION, A SUPPLEMENTAL REPORT WILL BE FILED.
IT WAS REPORTED THAT DRUG WAS INFUSED AND LEAKED FROM THE IV SET AN120 W/O BP DURING USE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: "AFTER CLAMPING THE TUBE, DRUG WAS INFUSED"
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 346821 | IV SET AN120 W/O BP | INTRAVASCULAR ADMINISTRATION SET | FPA | BECTON DICKINSON | 2811281 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Other |