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 11/26/2019

Event Type  malfunction  

Manufacturer Narrative

Concomitant medical products: sterrad® 100s sterilizer, serial # unknown.Initial reporter phone #: (b)(6).(b)(4).Test specifications for product release were met.No issues were observed in the dhr that would contribute to the complaint.Asp complaint ref #: (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 two 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 analysis of lot number, system risk analysis (sra), visual analysis, and retains analysis.Trending analysis by lot number was reviewed for the previous six months from open date and no further investigation or escalation is required at this time.The sra indicates the risk associated with exposure to biohazardous, pathogenic or infectious material is "low." thirty-two retains bis were subject to functional evaluation.All thirty-two bis met specification.The single cyclesure® 24 bi was not returned for visual inspection.However, a photograph of the product was provided.The photo shows two bis, the ci discs are not visible, the caps are depressed, and there is yellow media in both vials.An issue with sterrad® performance is unlikely as the cycle passed, the chemical indicator disc changed correctly, and the 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.The reported issue was not confirmed as the ci discs were not visible.There is no evidence to suggest an alleged deficiency since the dhr review found no anomalies that would contribute to a positive bi result and retains product met functional specifications.The customer was sent a letter to address the user error of releasing the load prior to reprocessing the issue will continue to be tracked and trended.Asp complaint ref #: (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: 9521838
• MDR Text Key: 185491359
• Report Number: 2084725-2019-01025
• 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: 12/04/2019

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: 01/31/2020
• Device Model Number: 14324
• Device Catalogue Number: 14324
• Device Lot Number: 9919017
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 12/04/2019
• Initial Date FDA Received: 12/26/2019
• Supplement Dates Manufacturer Received: 05/18/2020
• Supplement Dates FDA Received: 06/03/2020
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1