MAUDE Adverse Event Report: ADVANCED STERILIZATION PRODUCTS CYCLESURE® BIO INDICATOR; INDICATOR, BIOLOGICAL

Model Number 14324

Device Problem Appropriate Term/Code Not Available (3191)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 10/29/2019

Event Type  malfunction  

Manufacturer Narrative

Concomitant medical products: sterrad 100s sterilizer, serial #: unknown.(b)(4).

Event Description

A customer reported a positive result with a cyclesure® 24 biological indicator (bi) after a completed sterrad® 100s cycle.The bi was incubated for 24 hours.The chemical indicator (ci) changed color correctly.The previous and subsequent bi results were both negative.The affected load was released and used on a patient.There was no report of infection, injury or harm to patient(s) associated with this issue.Although there is no report of patient injury or harm and no prior incidents have resulted in serious injury, advanced sterilization products (asp) has determined in this situation sterility cannot be assured.Therefore, as a matter of policy asp had decided to report all incidents of positive cyclesure® 24 biological indicators when the load has been released and used on patient(s) prior to reprocessing.

Manufacturer Narrative

Asp investigation summary: the investigation included a review of the device history record (dhr), trending of lot number, system risk analysis (sra), visual analysis, retains analysis and concomitant product evaluation.The dhr was reviewed and the involved lot met manufacturer specifications at the time of release no issues were observed in the dhr that would contribute to the complaint.Trending analysis by lot number was reviewed from 02/20/2019 to 11/13/2019 and trending was not exceeded.The sra indicates the risk associated with exposure to biohazardous, pathogenic or infectious material is "low." visual analysis was performed on the photographs provided.The ci disc is yellow, the cap is depressed, and there is yellow media in the vial.Thirty-two retains bis were subject to functional evaluation.All thirty-two bis met specification.There is no evidence that the reported issue was related to the performance of the sterrad® 100s as the cycle passed, and the ci disc changed color correctly.Additionally, the previous and subsequent bis were negative for growth.The assignable cause is not verified.The complaint product was not returned for evaluation; however, the customer provided a photograph of the bi and the reported issue was confirmed.There is no evidence to suggest an alleged deficiency since the dhr review found no anomalies that would contribute to a positive bi result, retains product met functional specifications, and lot history review did not show any significant trend.There is no evidence that the reported issue was related to the sterrad® 100s unit¿s performance as the cycle passed, the ci disc changed color correctly, and the customer indicated that the previous and subsequent bis were negative for growth.The customer will be sent a letter to address the released load.The issue will continue to be tracked and trended.Asp complaint #: (b)(4).

• Brand Name: CYCLESURE® BIO INDICATOR
• Type of Device: INDICATOR, BIOLOGICAL
• Manufacturer (Section D): ADVANCED STERILIZATION PRODUCTS; 33 technology drive; irvine CA 92618
• MDR Report Key: 9366173
• MDR Text Key: 179506361
• Report Number: 2084725-2019-00998
• Device Sequence Number: 1
• Product Code: FRC
• UDI-Device Identifier: 10705037016211
• UDI-Public: 10705037016211
• Combination Product (y/n): N
• PMA/PMN Number: K994055
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup
• Report Date: 11/02/2019

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 Expiration Date: 10/31/2019
• Device Model Number: 14324
• Device Catalogue Number: 14324
• Device Lot Number: 05119011
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 11/02/2019
• Initial Date FDA Received: 11/22/2019
• Supplement Dates Manufacturer Received: 01/30/2020
• Supplement Dates FDA Received: 01/30/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1