C.R. BARD, INC. (COVINGTON) -1018233 BARDEX® I.C. TEMPERATURE SENSING FOLEY CATHETER; FOLEY CATHETER (LATEX)
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Catalog Number 129414M |
Device Problems
Deflation Problem (1149); Material Twisted/Bent (2981); No Flow (2991)
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Patient Problems
Urinary Retention (2119); Patient Problem/Medical Problem (2688)
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Event Date 11/13/2019 |
Event Type
malfunction
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Manufacturer Narrative
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The investigation is still in progress.Once the investigation is complete, a supplemental report will be filed.
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Event Description
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It was reported that there was no urine flow observed.This continued for 1 hour, then the user tried to remove the catheter for replacement, and found the balloon was difficult to deflate.An echo and ct scan were done and confirmed that the balloon part of the catheter was bent and placed.The user then cut the inflation lumen but no water would come out.A guidewire was inserted in to the inflation lumen, the balloon then deflated and the catheter was removed.Per additional information received via email on 9 december 2019 from ibc representative, the guidewire was used to deflate the balloon.There were no missing pieces of the balloon.
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Event Description
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It was reported that there was no urine flow observed.This continued for 1 hour, then the user tried to remove the catheter for replacement, and found the balloon was difficult to deflate.An echo and ct scan were done and confirmed that the balloon part of the catheter was bent and placed.The user then cut the inflation lumen but no water would come out.A guidewire was inserted in to the inflation lumen, the balloon then deflated and the catheter was removed.Per additional information received via email on 9 december 2019 from ibc representative, the guidewire was used to deflate the balloon.There were no missing pieces of the balloon.
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Manufacturer Narrative
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The reported issue was unconfirmed.The device was returned and visually inspected.Sample was evaluated and observed that there was no bent on the returned sample.Dissected the catheter and found no conditions that would contribute to the reported event.The exact cause on how and when the problem occurred could not be determine.The lot number is unknown; therefore, the device history record could not be reviewed.The instructions for use were found adequate and state the following: ¿[warnings] 1.Method for use (1) do not inflate the balloon in the urethra.[the urethra may be injured.] (2) do not pull the catheter hard.[the bladder/urethra may be injured.] 2.Applicable patients (1) patients with delirium who might pull out catheter [when patient tugs at catheter unconsciously, the bladder and urethra may be damaged.] [contraindications] 1.Method for use: (1) do not reuse.(2) do not resterilize.(3) be careful that the catheter is not exposed to ointments, contrast medium or oil-based lubricants (including vegetable oils such as olive oil, mineral oils such as white petrolatum and animal oils).[they may damage the device and may burst balloon.] (4) do not hold the device with forceps, etc.Avoid contact with any blades or sharp-edged instruments.[catheter damage may cause balloon rupture and accidental balloon removal or failure to deflate or remove the balloon.] 2.Applicable patients (1) patients who are or have been allergic to natural rubber latex (2) patients with known allergy to silver coated catheter." h11:section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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