It was reported, prior to an xray hysterosalpingogram using a cook silicone balloon hysterosalpingography (hsg) injection catheter, the device would not deflate.The physician tested the device prior to use on the patient by inflating with 1.5ml of air, but it failed to deflate.Another same type hsg device was tested and used to complete the procedure.No adverse effects were reported due to the alleged malfunction.
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H6: ec method code desc - 5: communication/interviews (4111).Investigation ¿ evaluation: iwk health centre informed cook on 17jan2020 of an incident involving a cook silicone balloon hysterosalpingography injection catheters (j-chsg-703000) from production lot 9877203.As reported, the complaint device was tested with air prior to use in a hysterosalpingogram procedure and would then not deflate.The procedure was successfully completed using another new cook hsg catheter.No adverse events were reported.A visual inspection and functional testing of the returned device was conducted.A document-based investigation was also performed including a review of complaint history, device history record, the instructions for use, manufacturing instructions, specifications, and quality control data.A visual examination confirmed the catheter was returned bowed and in used condition.The original package and label were not returned.Adequate adhesive was visible on the catheter.A functional test was performed by inflating the balloon with tap water.The balloon partially inflated and water leaked from the distal end near the catheter tip.Under magnification, the balloon material was stretched over the end of the catheter.Closer examination revealed the balloon was severed around the entire circumference of the balloon material.The separation occurred approximately 2-3mm from the end of the catheter.A review of the device history record (dhr) found no non-conformances related to the reported failure mode.A review of complaint history records shows two other complaints associated with the complaint device lot.Due to the individual nature of the manufacturing and inspection process for the devices in the lots, it is unlikely that these events are an indication of device issue within the entire lot.The instructions for use (ifu), provides the following information to the user related to the reported failure mode: warnings "always inflate the balloon with a sterile liquid.Never inflate with air, carbon dioxide or any other gas." precautions: "do not overinflate.Using excessive pressure to inflate the balloon on this device can cause the balloon to rupture." how supplied: "upon removal from the package, inspect the product to ensure no damage has occurred." a review of relevant manufacturing documents was conducted.It was concluded that the device aspect in question was visually/functionally inspected by quality control and no related gaps in production or processing controls were noted.Cook has concluded unintended user error contributed to this incident.Per the quality engineering risk assessment, no further action is warranted.Cook medical will continue to monitor this device via the complaints database for similar complaints.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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