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Catalog Number PTWS-2FLL-MLL-R |
Device Problem
Crack (1135)
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Patient Problem
No Patient Involvement (2645)
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Event Date 07/03/2018 |
Event Type
malfunction
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Manufacturer Narrative
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Pma/510(k) number = exempt.(b)(4).This report includes information known at this time.A follow-up report will be submitted should additional relevant information become available.
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Event Description
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It was reported, a leak was noted in three, three-way plastic stopcocks from two different lots during the same patient procedure.A transarterial chemoembolization (tace) procedure was being performed.The physician was attempting to mix an anticancer drug and contrast medium by utilizing the three-way plastic stopcock, when leakage through a crack in the stopcock was confirmed (reference medwatch 1820334-2018-02121).Two additional three-way plastic stopcocks from the same lot were then utilized and both presented with cracks and leakage, as well (reference medwatch 1820334-2018-02120).Subsequently, the physician successfully completed the procedure without using a three-way plastic stopcock.The patient did not experience any adverse effect due to this occurrence.Per the complainant, the used devices will not be returned to the manufacturer for investigation, as they were discarded at the user facility.After the event, multiple unopened three-way plastic stopcock packages from the same lot as the two consecutive devices used were opened for inspection.Cracks were noted by the customer in these devices as well (this report).These were not used in any procedure and will be returned for investigation.
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Manufacturer Narrative
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Blank fields on this form indicate the information is unknown, unavailable, or unchanged.Investigation ¿ evaluation.A review of the complaint history, device history record, documentation, drawing, manufacturing instructions, quality control, and a visual inspection and functional evaluation of the returned unused devices were conducted during the investigation.The devices matched the lot number of the complaint device.The actual complaint device was not returned for evaluation.The visual inspection of the returned representative devices confirmed the presence of cracks in the bodies of all the devices.All devices proceeded to leak when tested.Additionally, a document based investigation evaluation was performed.There is no evidence to suggest the product was not made to specifications.A review of the device history record showed no nonconforming events which could contribute to this failure mode.It should be noted there were no other reported complaints for this lot number.Based on the information provided, the examination of the returned representative products, and the results of our investigation, the root cause was determined to be related to the manufacturing processes of the devices.Measures are being conducted to address this failure mode.We will continue to monitor for similar complaints.Per the risk assessment no further action is required.This report is required by the fda under 21 cfr part 803.This report is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement made in it is intended to be an admission that any cook device is defective or malfunctioned; that a death or serious injury occurred; or that any cook device caused or contributed to; or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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Event Description
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No additional information regarding the patient and/or event has been received since the previous medwatch report was sent.Refer to section h10 for investigation findings.
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Search Alerts/Recalls
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