MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD OPTIFLOW JUNIOR INTERFACE; CAT

Model Number OPT318

Device Problem Device Handling Problem (3265)

Patient Problem High Oxygen Saturation (2478)

Event Date 06/22/2016

Event Type  malfunction  

Manufacturer Narrative

(b)(4).Method: the two complaint opt318 cannulae were received at fisher & paykel healthcare and were visually inspected.A third unsealed and undamaged cannula was received.An additional 30 sealed, unused cannulae were received.The unused samples were visually inspected and submitted to tensile strength testing to check the retention of the tubing in the swivel grip.Results: visual inspection of the two complaint cannulae revealed that in one case one of the flexitubes had become disconnected from the swivel grip and in the other case both tubes were detached from the swivel grip.A small amount of glue was present on the surfaces of both tubing and swivel grips.Visual inspection of the 30 unused cannulae showed that there was no visible damage or defect with any of them.All 30 were pull tested and the joint strength was found to be within specification, with no detaching of the tubing from the swivel grip.Conclusion: we were unable to determine what had caused the observed damage.All optiflow junior cannulae are 100% leak and occlusion tested after final assembly and any cannula that fails is discarded.In addition, samples are taken hourly from each run and pull tested to check glue joint strength at the cannula/tube joint, as well as the swivel grip joint.If there are any failures the entire batch is put aside for further investigation.The user instructions illustrate in pictorial format the correct set-up and proper use of the optiflow junior nasal cannula.They also state the following: - ensure that all connections are secure during use.Check cannula is undamaged and that the flow path is maintained.- appropriate monitoring must be used at all times.- do not stretch or crush tube.

Event Description

A hospital in (b)(6) reported that on two occasions a respiratory therapist found the opt318 optiflow junior nasal cannula tubing broken.This was initially reported to fisher & paykel healthcare as having occurred before patient use.Additional information was received on (b)(6) 2016 that one of the incidents had occurred during use on a patient, and that the patient's oxygen levels escalated.Confirmation was only received from the hospital on (b)(6) 2016 as to the number of incidents that had occurred.No further patient consequence was reported.

• Brand Name: OPTIFLOW JUNIOR INTERFACE
• Type of Device: CAT
• Manufacturer (Section D): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer (Section G): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer Contact: raymond yan ; 173 technology drive; suite 100; irvine, CA 92618 ; 9494534000
• MDR Report Key: 5927928
• MDR Text Key: 53904730
• Report Number: 9611451-2016-00512
• Device Sequence Number: 1
• Product Code: CAT
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 06/07/2016

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: OPT318
• Device Catalogue Number: OPT318
• Device Lot Number: 2100035782
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/09/2016
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 08/27/2016
• Initial Date FDA Received: 09/05/2016
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 04/01/2016
• 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