A customer reported the sterrad® sealsure chemical indicator tape did not change color correctly after a completed sterrad® nx cycle.The affected load was not released for use on patients, therefore there are no reports of infection, injury or harm to patient(s) associated with this issue.Although there is no report of patient injury or harm and no prior incidents have resulted in serious injury, advanced sterilization products (asp) has determined in this situation sterility cannot be assured.Therefore, as a matter of policy asp had decided to report all incidents of sterrad® sealsure chemical indicator tape not changing color correctly.
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Asp investigation summary: the investigation included a review of the device history record (dhr), trending analysis by lot number, retains analysis, system risk analysis (sra), concomitant product evaluation and visual analysis.¿ the dhr review, trending analysis by lot number and retains testing was not performed as the lot number was not available.¿ the sra indicates the risk associated with a quality problem with no impact on safety is "low." ¿ the concomitant sterrad nx was tested by a field service engineer and no problem was found.Color change appeared within normal range.¿ the product was not returned; therefore, no visual analysis was performed.There is insufficient information to determine an assignable cause.Multiple attempts at follow-up were made with the customer, but were unsuccessful.Should additional information become available, the complaint file will be re-opened and re-evaluated.The issue will continue to be tracked and trended.
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