As reported, prior to patient contact, a crack was found in a three-way plastic stopcock.The physician was mixing two liquids using two unknown syringes, and the liquid was reportedly "blowing up" due to the crack in the stopcock.The device did not make contact with any patient.There has been no report that the patient required any additional procedures or experienced any adverse effects due to this event.
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Blank fields on this form indicate the information is unknown, unavailable, or unchanged.Initial report.As reported, prior to patient contact, a crack was found in a three-way plastic stopcock.The physician was mixing two liquids using two unknown syringes, and the liquid was reportedly "blowing up" due to the crack in the stopcock.The device did not make contact with any patient.There has been no report that the patient required any additional procedures or experienced any adverse effects due to this event.Investigation evaluation.Reviews of the complaint history, device history record, drawing, manufacturer¿s instructions, quality control procedures, and visual inspection of the device were conducted during the investigation.The complaint device was not returned; however, used devices were provided for investigation under patient identifier (b)(6).Two prior-to-use ptws-2fll-mll-r stopcocks were returned in their individual packages along with two additional empty packages.No damage noted.Red-orange substance on stopcocks.A leak test was performed for both stopcocks.No leaks were found.Additionally, document-based investigation evaluation was performed.The evidence indicates the product was made to specifications.A review of the device history record shows no nonconforming events which could contribute to this failure mode.There were no non-conformances noted for this lot.No complaints for this lot have been reported.Adequate inspection activities have been established and there is objective evidence that the dhr was fully executed.Thus, there is no evidence to suggest that there are any nonconforming devices in the lot or in the field.Furthermore, reviews of the manufacturer¿s instructions, drawing, and quality control procedures were conducted, and no gaps were discovered.Based on the information provided and no product returned, investigation has concluded that a root cause for this event could not be determined.We will continue our monitoring of similar complaints and have notified the appropriate personnel of this event.Per the quality engineering 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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