Concomitant product: boston scientific 5-4-3 tip style contour ercp cannula.Investigation evaluation: our evaluation of the product said to be involved confirmed the report.There is wire guide coating damage near the distal end.The wire guide was returned in the wire guide holder.The wire guide holder appears to have been flushed with saline/water.The coil spring is still attached to the distal end of the wire guide.Approximately 6.6 cm to 8 cm from the distal end is a section of bare core wire, the section of the coating appears to be missing.The wire guide coating from the bare section of core wire was not provided with the return.No rough surfaces or kinks are found along the wire guide.A product-specific discrepancy that could have caused or contributed to this observation was not observed during our laboratory analysis.The device history record for the lot number said to be involved was reviewed.A discrepancy or anomaly was not observed with the product that was released for distribution.Investigation conclusion: a definitive cause for this observation could not be determined because the actual use conditions could not be duplicated in the laboratory setting.Due to a variety of clinical conditions such as patient anatomy, endoscope position or progression of disease state, we could not reproduce the actual conditions of product usage during our laboratory analysis.This limits our ability to conclusively determine a cause.The instructions for use indicates, "this wire guide may be left in place when used under normal conditions in conjunction with, and according to the instruction for, a compatible cook electrosurgical (es) device." the product involved in this report, a 0.21 in metii-21-480 wire guide, was used with the 5-4-3 tip style contour ercp cannula from boston scientific.However, the boston scientific catalog recommends the cannula be used with a.018 in wire guide.Prior to distribution, all tracer metro direct wire guides are subjected to a visual inspection and functional testing to ensure device integrity.A review of the device history record confirmed that the lot said to be involved met all manufacturing requirements prior to shipment.Corrective action: a review of the complaint history was conducted and this represents an unusual occurrence.The likelihood of occurrence is considered remote.Corrective action is not warranted at this time based on the quality engineering risk assessment.Quality assurance will continue to monitor for complaint trends and reassess the risk assessment results as post market feedback continues to become available.Additional comments regarding this report: based on the information provided that the cook wire guide was used with an incompatible device, a cook representative has been directed to contact the medical facility involved in an effort to promote further education and understanding related to appropriate usage of this product.
|