MAUDE Adverse Event Report: ASPEN SURGICAL PRODUCTS, CALEDONIA RICHARD ALLAN MODERN REG TIP PEN W/ RULER & 6-UP LABELS; MARKING PEN

Model Number 2750

Device Problem Defective Component (2292)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 05/28/2019

Event Type  malfunction  

Manufacturer Narrative

Aspen surgical received a report from the distributor that product was found with seal issues.The actual device was returned for evaluation.The manufacturing lot number was provided for review as well.The return of the sample confirmed the issue identified from the distributor.Analysis of the finished good lot number was reviewed.No non-conformance's were noted during the manufacturing process.Upon review of the samples, the seals on the film show incomplete transfer of adhesive.This incomplete seal can be caused by unexpected process interruptions identified in operating instructions.Additionally, according to the manufacturing process, these parts are manually loaded into recessed pockets on a packaging machine per specified work instructions.If incorrectly loaded or not orientated properly, this will cause an incomplete seal.Therefore a likely root cause for the seal issue may be attributed to an operator error.The pouch label, identifies this failure mode with the symbol "do not use if package is damaged".This indicates that the device should not be used if the products sterile barrier system or its packaging is compromised.Additionally, production supervisors and operation were notified of this issue during the daily update meetings.Based on this information, no further action is required.

Event Description

Aspen surgical received a report from the distributor indicating that richard-allan regular tip pen was found with defective seals.The item was not in use.No injury/death was reported.This report was filed in our complaint handling system as number (b)(4).

• Brand Name: RICHARD ALLAN MODERN REG TIP PEN W/ RULER & 6-UP LABELS
• Type of Device: MARKING PEN
• Manufacturer (Section D): ASPEN SURGICAL PRODUCTS, CALEDONIA; 6945 southbelt dr. s.e.; caledonia MI 49316
• Manufacturer (Section G): SAME AS ABOVE
• Manufacturer Contact: jordan hackert ; 6945 southbelt dr. s.e.; caledonia, MI 49316 ; 6165367508
• MDR Report Key: 8707378
• MDR Text Key: 151427187
• Report Number: 1836161-2019-00050
• Device Sequence Number: 1
• Product Code: FZZ
• Combination Product (y/n): N
• Reporter Country Code: GM
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 05/28/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/18/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Device Model Number: 2750
• Device Lot Number: 179092
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 05/28/2019
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 11/17/2018
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1