DUODERM/GRANUFLEX/DUOACTIVE - MOISTURE RETENTIVE DUODERM CGF DRESSING
Report
- Report Number
- 9618003-2020-07775
- Event Type
- Malfunction
- Date Received
- April 8, 2020
- Manufacturer
- CONVATEC DOMINICAN REPUBLIC INC
- Product Code
- NAD
- PMA / PMN Number
- EXEMPT
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- GA
- Reporter Occupation
- OTHER
- Health Professional
- N
Narratives
SUMMARY OF THE RELATED EVENT: A QUERY RAN ON 14/JAN/2021 IN TRACKWISE SYSTEM VERSION 8.7, SHOWED THAT A TOTAL OF TWENTY (21) CUSTOMER COMPLAINTS (PARENTS) REPORTED ARE STILL OPEN, PENDING FOR CHILD INVESTIGATION (SEVEN (7) COMPLAINTS IN TOTAL, INCLUDING TYPE 3) COMPLAINTS FOR LOTS MANUFACTURED AT THE CONVATEC INC. HAINA PLANT IN BODOLAY MANUFACTURING LINES RESPECTIVELY, DUE TO MALFUNCTION CODE WND-PMC03.08 ADHESIVE DRESSING REQUIRES EXCESSIVE FORCE FOR REMOVAL FROM SKIN (I.E. DIFFICULT TO REMOVE). THE PROBLEMS REPORTED WERE RELATED TO ¿DIFFICULT TO REMOVE DRESSING FROM SKIN ¿. IN THIS NONCONFORMANCE REPORT ALL COMPLAINTS CONSIDERED HEREIN HAVE THE SAME SEVERITY NUMBER OF 4. HARM WAS REPORTED BY THE COMPLAINANT INVOLVED (HC13.1 TISSUE DAMAGE, HC12.2 SKIN IRRITATION / RASH / MUCOSAL IRRITATION, HC1.4 ALLERGIC REACTION). PHOTOS WERE RECEIVED FOR COMPLAINT TW# 1166663, TW# 1212633, TW# 1323646, TW# 1396983, TW# 1398234 & TW# 1398235. THE FOLLOWING COMPLAINTS INVESTIGATION WERE REPORTED FROM 14/MAY/2018 TO 30/DEC/2020. FOR MORE DETAIL REFER TO THE TABLE TABLE # 1 DATA FOR AFFECTED PRODUCT. HISTORICAL COMPLAINTS REVIEW: ON 22 MAR 2021, COMPLAINTS INVESTIGATOR ID 3687 RAN A QUERY IN TRACKWISE 8.7 IN ORDER TO VERIFY THE COMPLAINTS REPORTED FOR THE LOTS NUMBERS INVOLVED AND AS RESULT, NO ADDITIONAL COMPLAINTS WERE REPORTED. HISTORICAL NONCONFORMANCE REVIEW: ON 22 MAR 2021, COMPLAINTS INVESTIGATOR ID 3687 RAN A QUERY IN TRACKWISE 8.7 LOOKING FOR ANY NONCONFORMANCE / CAPA (S) ASSOCIATED TO THE FAILURE MODE ¿DIFFICULT TO REMOVE DRESSING FROM SKIN¿ FOR THE LOTS NUMBERS INVOLVED AND AS RESULT, NO NONCONFORMANCE / CAPA (S) FOR THESE FAILURE MODE WERE GENERATED DURING THE MANUFACTURING PROCESS OF THE REFERENCED LOTS. BATCH RECORD REVISION RESULTS: ON 22 MAR 2021, A BATCH RECORD REVIEW WAS PERFORMED BY COMPLAINT INVESTIGATOR 3687, FOR BULK LOTS NUMBERS IN THE TABLE #2, WERE MANUFACTURED IN THE ELC #10, ELC #11. A REVISION WAS CONDUCTED AND REVIEW THE TESTING PERFORMED THAT IS AS FOLLOW: ALL THE TEST ARE PERFORMED FOLLOWING PROCESS INSTRUCTIONS PI31-103 VERSION 3.0 TO 11.0 -FOR ELC #10 AND PI31-141 REVISION 1.0 TO 2.0. ELC #11. THE ROLLING BALL, ADHESIVE TEST PER TM-011, STRIP TO STRIP, T-PEEL, VISUAL INSPECTION PER TM-017. THE OVERALL THICKNESS AND MASS THICKNESS ALSO FOR TM-011, THE TM-085: DETERMINATION OF BOND STRENGTH, EVERY ½ HOUR AND DOCUMENTED IN THE BR31-14, VERSION 1.0. THE BULK LOTS FOR THE MASS FORMULATION ARE SHOWN IN THE TABLE ATTACHMENT 1, DESCRIPTION MASS 177A, MACHINE WORKCENTRE AMK MIXER LARGE #2 (MIXER 6), WORKCENTRE AMK MIXER LARGE #3 (MIXER 7).THOSE LOTS WERE MANUFACTURED FOLLOWING THE APPLICABLE PROCEDURES, ALL MACHINE AND TESTING PARAMETERS WERE IN ACCORDANCE WITH THE APPLICABLE PROCEDURES AND SPECIFICATIONS PI22-084 SHORT CYCLE AMK MIXING 1002207 177-A (WORK CENTER 105) VERSION 7.0. IN THIS LINE QA PERFORMED A VISUAL INSPECTION EVERY TWO (2) HOUR AND DOCUMENTED THE RESULTS IN THE APPLICABLE ANNEXES FROM DR-SOP-0063, VERSION 20.0. WITH SATISFACTORY RESULTS, NO NC OR DISCREPANCIES WERE NOTICED DURING THIS BATCH RECORDS REVIEW. ACCORDING TO THE INSTRUCTION FOR USED CORRESPONDING TO THE LOTS REPORTED BY THE CUSTOMER (SEE TABLE #1) REMOVING THE DRESSING: PRESS DOWN ON THE SKIN AND CAREFULLY LIFT AND EDGE OF THE DRESSING. CONTINUE AROUND UNTIL ALL EDGES ARE FREE. REPEAT CLEASING PROCEDURES. IT IS UNNECESARY TO REMOVE ALL RESIDUAL DRESSING MATERIAL FROM THE SORROUNDING SKIN. LEAVE THE DRESSING IN PLACE, (NOT MORE THAN 7 DAYS) UNLESS IT IS UNCOMFORTABLE, LEAKING, OR THERE ARE CLINICAL SIGNS OF INFECTION. ACCORDING TO THE DESCRIPTION OF THE DEFECT REPORTED BY THE CLIENT, SOME DID NOT REPORT HARM, OTHERS REPORTED HARM WITH A DRESSING DURATION OF 1 TO 12 DAYS. THEY DO NOT DESCRIBE THE METHOD OF CLEANSING THE SKIN. PROCESS DESCRIPTION: A REVISION OF THE ASSEMBLY PROCESS DESCRIBED IN THE APPLICABLE PROCESS INSTRUCTIONS (SEE GRAPH ABOVE FOR REFERENCE) WERE PERFORMED IN ORDER TO DETERMINE IN WHICH PART OF THE PROCESS THE REPORTED DEFECT CAN BE GENERATED. PROCESS SUMMARY: PI31-103 PROCESS INSTRUCTIONS FOR ELC 10, 6.3 PROCESS SUMMARY: (DRESSING DUODERM® EXTRA THIN) DUODERM® EXTRA THIN: 177-A MASS THAT HAS AGED NOT LESS THAN 3 HOURS SINCE DISCHARGE FROM MIXER IS PLACED INTO THE EXTRUDER HOPPER WHERE IT IS FED TO THE EXTRUDER BY THE COMBINED ACTIONS OF TWO FEED ROLLS AND THE EXTRUDER SCREW. ROPED OR LOG FEED STOCK MAY BE USED. THE MASS IS CONVEYED, COMPRESSED, HEATED, AND FORMED INTO AN ADHESIVE SHEET BY THE ACTIONS OF THE EXTRUDER SCREW, BARREL, AND DIE. ONCE EXTRUDED, THE MASS IS CALENDERED TO SPECIFIED THICKNESS AND LAMINATED WITH A LAYER OF MEDIFILM COATED PAPER (TOP) AND A LAYER OF SRP. A RELEASE LINER IS ADDED DURING CALENDERING TO CREATE AN EASY PEEL TAB IN THE FINAL PRODUCT. THE FOUR LAYERS - PAPER, MASS, RELEASE LINER, AND MEDIFILM -- ARE DRAWN THROUGH A ROTARY DIE AND CUT TO THE PROPER DIMENSION. THE COMPLETED DRESSINGS ARE INSPECTED AND STACKED ONTO TRAYS TO BE PLACED ON A BULK STORAGE RACK TO AWAIT THE NEXT PROCESSING STEP. PROCESS SUMMARY: MIXER, THE ASPIRATION FILTER AND NITROGEN GENERATION SYSTEMS MUST BE OPERATING BEFORE THE PROCESS CAN BEGIN. ALL COMPONENTS MUST BE WEIGHED BEFORE BEGINNING THE ACTUAL MIXING PROCESS. COMPONENTS ARE ADDED AS SPECIFIED TO AMK SIGMA BLADE KNEADER-EXTRUDER M07 (WORK CENTER17001105), HEATED TO A SPECIFIC TEMPERATURE, AND KNEADED FOR A PRESCRIBED LENGTH OF TIME. THE STYRENE-ISOPRENE-STYRENE (SIS) COMPONENT IS PRE-PROCESSED IN AN EXTRUDER PRIOR TO ADDITION TO THE MIXER. THE COMPOUNDED MASS IS DISCHARGED THROUGH THE EXTRUDER AT THE BASE OF THE MIXER AND CUT INTO LOAVES. THE LOAVES ARE PLACED ONTO RACKS OF TRAYS LINES WITH SILICONE RELEASE PAPER UNTIL DELIVERY TO THE NEXT PROCESSING STEP. RISK EVALUATION: THE REPORTED CONDITION IS WND-PMC03.08 ADHESIVE DRESSING REQUIRES EXCESSIVE FORCE FOR REMOVAL FROM SKIN (I.E. DIFFICULT TO REMOVE). SOME HARM WAS REPORTED FOR THE COMPLAINANTS REPORTED. AS PER ¿WI-0461 PHRI-002-WND¿ VERSION 1.0, SEVERITY REPORTED FOR THOSE CASES IS LOW. THE HIGHEST ACTUAL SEVERITY REPORTED HAS BEEN HC5.3 INFECTION. THE SEVERITY FOR THIS PMC REMAINS UNCHANGED BASED ON THE POTENTIAL FOR RECURRENCE. THIS MALFUNCTION WILL NOT BE REPORTED AND WILL BE CONTINUOUSLY MONITORED AND REVIEWED FOR ANY CHANGES IN THE OBSERVED ACTUAL SEVERITY. CONCLUSIONS: BASED ON THE RESULTS OF THE PRELIMINARY INVESTIGATION, SOME HARM WAS REPORTED FROM THE COMPLAINANTS, PHOTOS IS AVAILABLE FOR EVALUATION, NO SAMPLES ARE AVAILABLE FOR TESTING. BASED ON THE EVALUATED PHOTOS, COMPLAINT REPORTED HAVE BEEN CONFIRMED. NEVERTHELESS, NO ADDITIONAL ACTION IS REQUIRED, DUE TO, ACCORDING TO THE PRELIMINARY INVESTIGATION AND EVALUATIONS PERFORMED DURING THE MANUFACTURING PROCESS, IT WAS CONCLUDED THAT THIS DEFECT COULD NOT BE GENERATED DURING THE MANUFACTURING PROCESS. TO DATE NO ADDITIONAL INFORMATION HAS BEEN RECEIVED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED. FDA REGISTRATION NUMBER REPORTING SITE: 1049092 MANUFACTURING SITE: 9618003
TO DATE NO ADDITIONAL PATIENT OR EVENT DETAILS HAVE BEEN RECEIVED.
DEVICE 1 OF 3. BASED ON THE AVAILABLE INFORMATION, THIS EVENT IS DEEMED TO BE A REPORTABLE MALFUNCTION. TO DATE NO ADDITIONAL INFORMATION HAS BEEN RECEIVED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED (B)(4).
IT WAS REPORTED BY THE SPOUSE OF THE END USER THAT "HE HAD GREAT DIFFICULTY REMOVING THE DRESSING FROM STAGE ONE (1) PRESSURE INJURY AFTER FIVE (5) DAYS WEAR TIME, RESULTING IN SCANT SKIN TEARS". IT IS ALSO REPORTED THAT "THE SKIN HAS NOW HEALED AND IS PURPLISH PINK, AND INTACT". THE END USER HAD A ROUTINE FOLLOW-UP AT THEIR WOUND CENTER AND THEIR HEALTH CARE PROVIDER (HCP) ADVISED THEM TO STOP USING THE PRODUCT AND COVER WITH GAUZE AND ALTERNATIVE PRODUCT BORDER DRESSING INSTEAD. NO PHOTOGRAPHS DEPICTING THE REPORTED COMPLAINT ISSUE WERE SUBMITTED BY THE COMPLAINANT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 405110 | DUODERM/GRANUFLEX/DUOACTIVE - MOISTURE RETENTIVE DUODERM CGF DRESSING | DRESSING,WOUND,OCCLUSIVE | NAD | CONVATEC DOMINICAN REPUBLIC INC | 187955 | 9H00185 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | Male |