It was reported that a three-way plastic stopcock was found to be leaking fluid.This was observed prior to patient contact, and another similar device was used to complete the procedure.The type of procedure was not provided.The patient did not require any additional procedures due to this occurrence.According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.
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Investigation evaluation: a review of the dimensional verification, complaint history, device history record, documentation, drawing, manufactures instructions, quality control, specifications, and a functional test & visual inspection of the returned device were conducted during the investigation.The visual inspection of the returned device confirmed that the stopcock and two syringes were attached with purple contrast.The device was noted to be cracked on the body from front to back.During the functional test, a leak was noted through the crack when material was injected from the top fitting.However, when the side entry was tested, no leaks due to the blockage.It should also be noted that the thru-hole was blocked by the purple contrast as well.Additionally, a document based investigation evaluation was performed.There is no evidence to suggest the product was not made to specifications.A review of the device history record showed no nonconforming events which could contribute to this failure mode.It should be noted there was one other reported complaint for this lot number.Furthermore, a review of the manufactures instructions and documentation revealed relevant information surrounding the mold used for this device.The material used for this device has the potential to absorb moisture, resulting in an increase in diameter, thus raising the potential for cracking the stopcock body.Based on the information provided, the examination of the returned product, and the results of our investigation, a definitive root cause can be traced to device designed.Measures are being conducted to address this failure mode.We will continue our monitoring of similar complaints and have notified the appropriate personnel of this event.Per the quality engineering risk assessment no further action is required.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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