MAUDE Adverse Event Report: STERIS MEXICO, S. DE R.L. DE C.V. V-PRO MAX 2 STERILIZER

Model Number max 2

Device Problem Use of Device Problem (1670)

Patient Problem Burn(s) (1757)

Event Date 05/26/2022

Event Type  malfunction  

Manufacturer Narrative

The user facility reprocessed the instruments present during the time of the reported event.A steris service technician arrived onsite following the reported event to inspect the sterilizer.The technician inspected the sterilizer and found the unit to be operating properly.No issues with the function or operation of the sterilizer were identified and the sterilizer was returned to service.User facility personnel should ensure all instruments are properly dry prior to placement in the v-pro max 2 sterilizer.The v-pro max 2 operator manual, (a-1) states, "dry all items thoroughly.Ensure all moisture is removed from all internal parts (including lumens).If not, residual hydrogen peroxide may remain at cycle completion and/or a cycle abort occurs.Only dry items are to be placed in sterilization unit." through follow-up with user facility personnel, the technician was informed that the employee was not wearing proper ppe, specifically gloves as stated in the operator manual.The v pro max 2 sterilizer operator manual states (6-16), "steris recommends (in accordance with ansi/aami guidelines) wearing chemical-resistant gloves when using the sterilization unit." "if visual soil or moisture is present, clean and dry load again." the operator manual further states (1-2), "danger - chemical injury hazard: any visible liquids in the chamber or on the load must be treated as concentrated hydrogen peroxide.Observe all hydrogen peroxide handling precautions.When handling hydrogen peroxide, wear appropriate personal protective equipment." the technician counseled user facility personnel on the proper use and operation of the v-pro max 2 sterilizer, specifically to properly dry instruments prior to placement in the sterilizer, and to wear appropriate ppe when handling instruments that have been processed in the unit.

Event Description

The user facility reported that an employee experienced a burn while handling items that were processed in their v-pro max 2 sterilizer.The employee sought medical treatment.

• Brand Name: V-PRO MAX 2 STERILIZER
• Type of Device: STERILIZER
• Manufacturer (Section D): STERIS MEXICO, S. DE R.L. DE C.V.; avenida avante 790; parque industrial guadalupe; guadalupe, 67190 ; MX 67190
• Manufacturer (Section G): STERIS MEXICO, S. DE R.L. DE C.V.; avenida avante 790; parque industrial guadalupe; guadalupe, 67190 ; MX 67190
• Manufacturer Contact: daniel davy ; 5960 heisley road; mentor, OH 44060 ; 4403927453
• MDR Report Key: 14775724
• MDR Text Key: 301836981
• Report Number: 3005899764-2022-00025
• Device Sequence Number: 1
• Product Code: MLR
• UDI-Device Identifier: 00724995158354
• UDI-Public: 00724995158354
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date: 06/22/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Health Professional
• Device Model Number: max 2
• Device Catalogue Number: VP50002101
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 05/26/2022
• Initial Date FDA Received: 06/22/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 05/27/2021
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1