FDA Adverse Event Malfunction Summary report: N

BD VACUTAINER® ECLIPSE¿ BLOOD COLLECTION NEEDLE

MDR report key: 8575720 · Received May 2, 2019

Report

Report Number
1024879-2019-00819
Event Type
Malfunction
Date Received
May 2, 2019
Date of Event
April 17, 2019
Report Date
May 20, 2019
Manufacturer
BECTON, DICKINSON & CO., (BD)
Product Code
FMI
UDI-DI
50382903686075
PMA / PMN Number
K982541
Adverse Event
Yes
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
FL, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 0

INVESTIGATION SUMMARY: BD HAD NOT RECEIVED SAMPLES OR PHOTOS FROM THE INCIDENT LOT 9003943; HOWEVER, THE CUSTOMER PROVIDED SAMPLES FROM LOT 8298865. THE SAMPLES WERE EVALUATED AND THE CUSTOMER'S INDICATED FAILURE MODE FOR SAFETY SHIELD SEPARATION WITH THE INCIDENT LOT WAS OBSERVED. A REVIEW OF THE DEVICE HISTORY RECORD WAS COMPLETED FOR BOTH LOTS AND, BASED ON THIS REVIEW, ALL PRODUCT SPECIFICATIONS AND REQUIREMENTS FOR LOT RELEASE WERE MET; THERE WERE NO RELATED QUALITY NON-CONFORMANCES DURING MANUFACTURING OF THE PRODUCT. INVESTIGATION CONCLUSION: BASED ON EVALUATION OF THE CUSTOMER SAMPLES, THE CUSTOMER¿S INDICATED FAILURE MODE FOR SAFETY SHIELD SEPARATION WITH THE INCIDENT LOT WAS OBSERVED. ROOT CAUSE DESCRIPTION: BASED ON THE INVESTIGATION, A ROOT CAUSE COULD NOT BE DETERMINED. RATIONALE: COMPLAINTS RECEIVED FOR THIS DEVICE AND REPORTED CONDITION WILL CONTINUE TO BE TRACKED AND TRENDED. INFORMATION WILL BE CAPTURED ON TREND REPORTS AND MONITORED. THE BD BUSINESS TEAM REGULARLY REVIEWS THE COLLECTED DATA FOR IDENTIFICATION OF EMERGING TRENDS.

Description of Event or Problem · 0

IT WAS REPORTED THAT SAFETY SHIELD FALLS OFF FROM THE VACUTAINER HOLDER WITH A BD VACUTAINER® ECLIPSE¿ BLOOD COLLECTION NEEDLE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: IT WAS REPORTED THAT THE SHIELD FALLS OFF FROM THE VACUTAINER HOLDER LEAVING THE NEEDLE UNCOVERED AND RISKING THE SAFETY OF THE PHLEBOTOMIST. UNFORTUNATELY, IN THE LAST FEW DAYS WE HAVE BEEN MADE AWARE BY THE STAFF OF A CURRENT SAFETY ISSUE THAT HAS BEEN HAPPENING FOR A FEW WEEKS WITH OUR NEW BD VACUTAINER/NEEDLES ECLIPSE. THE ISSUE IS, THAT AT TIMES WHEN THE PHLEBOTOMIST ARE GOING TO CLOSE THE SAFETY SHIELD OF THE NEEDLE AFTER A BLOOD COLLECTION THE SHIELD HAS FALLEN OFF FROM THE VACUTAINER HOLDER LEAVING THE NEEDLE UNCOVERED AND RISKING THE SAFETY OF THE PHLEBOTOMIST. SHE MENTIONED THAT THIS IS NOT A NEW ISSUE FOR THIS PRODUCT. IN ADDITION, ANOTHER CONCERN FROM OUR PHLEBOTOMISTS IS THAT VERY OFTEN AFTER TIGHTENING THE NEEDLES TO THE VACUTAINER HOLDER, THE NEEDLES DO NOT ALIGN PROPERLY WITH THE CENTER OF THE HOLDER MAKING IT HARDER TO HOLD DURING BLOOD COLLECTION. AS WE CONTINUE THE TRANSITION TO THIS PRODUCT WE ARE EXTREMELY WORRIED AND UNSURE HOW OUR LARGEST FACILITY IS GOING TO DEAL WITH THESE ISSUES TAKING INTO CONSIDERATION THAT 99% OF BLOOD COLLECTION AT THIS FACILITY IS PERFORMED BY NON-LAB PERSONNEL. NO PATIENT IDENTIFIERS AVAILABLE.

Additional Manufacturer Narrative · 1

DATE OF EVENT: UNKNOWN. THE DATE RECEIVED BY MANUFACTURER HAS BEEN USED FOR THIS FIELD. A SAMPLE IS AVAILABLE FOR EVALUATION. UPON COMPLETION OF THE INVESTIGATION, A SUPPLEMENTAL REPORT WILL BE FILED.

Description of Event or Problem · 1

IT WAS REPORTED THAT SAFETY SHIELD FALLS OFF FROM THE VACUTAINER HOLDER WITH A BD VACUTAINER® ECLIPSE¿ BLOOD COLLECTION NEEDLE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: IT WAS REPORTED THAT THE SHIELD FALLS OFF FROM THE VACUTAINER HOLDER LEAVING THE NEEDLE UNCOVERED AND RISKING THE SAFETY OF THE PHLEBOTOMIST. UNFORTUNATELY, IN THE LAST FEW DAYS WE HAVE BEEN MADE AWARE BY THE STAFF OF A CURRENT SAFETY ISSUE THAT HAS BEEN HAPPENING FOR A FEW WEEKS WITH OUR NEW BD VACUTAINER/NEEDLES ECLIPSE. THE ISSUE IS, THAT AT TIMES WHEN THE PHLEBOTOMIST ARE GOING TO CLOSE THE SAFETY SHIELD OF THE NEEDLE AFTER A BLOOD COLLECTION THE SHIELD HAS FALLEN OFF FROM THE VACUTAINER HOLDER LEAVING THE NEEDLE UNCOVERED AND RISKING THE SAFETY OF THE PHLEBOTOMIST. SHE MENTIONED THAT THIS IS NOT A NEW ISSUE FOR THIS PRODUCT. IN ADDITION, ANOTHER CONCERN FROM OUR PHLEBOTOMISTS IS THAT VERY OFTEN AFTER TIGHTENING THE NEEDLES TO THE VACUTAINER HOLDER, THE NEEDLES DO NOT ALIGN PROPERLY WITH THE CENTER OF THE HOLDER MAKING IT HARDER TO HOLD DURING BLOOD COLLECTION. AS WE CONTINUE THE TRANSITION TO THIS PRODUCT WE ARE EXTREMELY WORRIED AND UNSURE HOW OUR LARGEST FACILITY IS GOING TO DEAL WITH THESE ISSUES TAKING INTO CONSIDERATION THAT 99% OF BLOOD COLLECTION AT THIS FACILITY IS PERFORMED BY NON-LAB PERSONNEL. NO PATIENT IDENTIFIERS AVAILABLE

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
369643 BD VACUTAINER® ECLIPSE¿ BLOOD COLLECTION NEEDLE HYPODERMIC SINGLE LUMEN NEEDLE FMI BECTON, DICKINSON & CO., (BD) 9003943 50382903686075

Patients

Seq Age Sex Outcome Treatment
1 Other