A review of the device history records was performed for the reported packaging lot for any deviations related to the reported defect of the complaint.The review confirms that the lot met all material, assembly and performance specifications.The angiodynamics complaint report was reviewed for the stopcock product family and the failure mode,"package - hole/perforated." no adverse trends were identified.The returned sample was visually inspected and the hole in the stopcock pouch was confirmed.The root cause of the hole is that the handle from the stopcock presses outward against the tyvek.As part of the receiving process at nipro (the distributor in (b)(4)), all pouched products are removed from their inner boxes and a nipro label (in (b)(4)) is applied to each pouch and inner box.Additional handling may occur if product is 100% visually inspected.The pouched product is then re-boxed into the inner box by the nipro warehouse employees.The hole in the tyvek was likely caused by the handle of the stopcock in the pouch, however, what caused the handle to be pushed against the tyvek in a manner that resulted in a hole cannot be determined.A recent revision to the packaging materials for the stopcocks included a change to a deeper inner box with the intention of reducing the chances of over-crowding of product within the box.The lot of product from this reported event was packaged after implementation of this change.Potential contributing factors to the pouch damage include: handling during transit to nipro warehouse.Handling during nipro labeling/inspection and re-boxing process.All pouches are 100% inspected per angiodynamics procedures during the sealing and final box processes.Employees involved in the packaging/final boxing of the reported lot of product have been made aware of this complaint.The directions for use (dfu) packaged with the stopcocks contain the following warning: "contents supplied sterile using an ethylene oxide (eo) process.Do not use if sterile barrier is damaged." (b)(4).
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As reported by angiodynamics' distributor in (b)(4), in the distributor's warehouse a small hole was found in the tyvek portion of a stopcock pouch, breaching the sterility.The device had not been provided to a hospital and was returned to angiodynamics for evaluation.
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