Catalog Number 1251CSF1 |
Device Problem
Physical Resistance/Sticking (4012)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 01/13/2022 |
Event Type
malfunction
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Event Description
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It was reported that during a brachytherapy procedure, the last two seeds of the device allegedly could not be discharged from the loader.It was further reported that one of the seeds were ejected by pushing the plunger but seed from the other cartridge failed to eject.The last seed was removed from applicator by flipping and shaking the plunger.There was no reported patient injury.
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Manufacturer Narrative
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As the lot number for the device was not provided, a review of the device history records could not be performed.The return of the sample is pending.The investigation of the reported event is currently underway.
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Event Description
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It was reported that during a brachytherapy procedure, the last two seeds of the device allegedly could not be discharged from the loader.It was further reported that one of the seeds were ejected by pushing the plunger but seed from the other cartridge failed to eject.The last seed was removed from applicator by flipping and shaking the plunger.There was no reported patient injury.
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Manufacturer Narrative
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Manufacturing review: a device history record review was performed for the affected lot number of the cartridge raw material and seeds.These lot met all release criteria.No issues were noted.Investigation summary: one modified mick-15 cartridge was returned from the customer for evaluation and was labeled as biohazardous.The cartridge was inspected and nothing unusual was noted on the outside.The modified mick -15 cartridge was loaded with 15 non-radioactive brachyseeds / sourcecaps and were inserted into a mick applicator.All 15 non-radioactive brachyseeds / sourcecaps from the cartridge dispensed as expected.Upon completion of dispensing, the cartridge was removed from the applicator and examined.Nothing unusual was noted.Therefore, the investigation is not confirmed for the reported issue.A definitive root cause could not be determined based upon the available information.Labeling review: labeling was reviewed and found to be adequate.The instruction for use was reviewed for modified mick 15.There is a warning section stating how to handle the magazine when loaded with seeds as well as warning of over tightening the magazine head to the base.H11: section a through f ¿ the information provide by bd represents all the known information at this time.Despite good faith efforts to obtain additional information, the complainant/reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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Search Alerts/Recalls
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