MAUDE Adverse Event Report: CONVATEC DOMINICAN REPUBLIC INC ACTIVELIFE; POUCH, COLOSTOMY

Model Number 175782

Device Problem Malposition of Device (2616)

Patient Problems Tissue Damage (2104); Blood Loss (2597)

Event Type  malfunction  

Manufacturer Narrative

Device 15 of 19.Based on the available information, this event is deemed to be a reportable malfunction.To date no additional information has been received.Should additional information become available, a follow-up report will be submitted.(b)(4).

Event Description

The end user estimated about 3 pouches from each of the 6 market units that were affected.The precut opening in the convex mass was very off centered.She stated that the off centered barrier had caused her to develop an open sore at the 9 o'clock position, approximately 13 x 25mm with some bleeding.Her wear time was 3 days.Reportedly, she had been seen by a local ostomy nurse.She was wearing a hernia belt, but recently stopped using the belt.She further reported that the sore now appeared to be healing with new skin and there was no bleeding with last wafer change.The patient continued to use the product.Photographs depicting the issue were received from the end user.

Manufacturer Narrative

Additional information - this emdr is being submitted to include the below: d4: unique identifier (udi) h6: investigation results under imdrf cause investigation code, imdrf investigation findings, imdrf cause conclusions h10: investigation summary an investigation was completed for this complaint by the assigned manufacturing site investigation team.The complaint summary of this investigation required rework.A corrective actions/preventive actions (capa) was raised, and an updated/corrected investigation summary has been completed in accordance with assigned capa.A supplemental mdr is being submitted to document the completion of investigation rework and final investigation; the complaint record will proceed to closure.Batch record review: lot 0c02789 was manufactured on 04/14/2020, in the convex 1pc line with a total of (b)(4) ea.Compliance engineer performed a batch record review on 02/26/2021, to verify if all the applicable procedures were followed and no issues were found, all the components for assembly were correct per bill of materials (bom) and all the tooling information documented was also correct, under international commodity code (icc) code 175782, system application product (sap) material identification (id) 1000626 and manufacturing order (b)(4).The batch record review supports that there were no discrepancies related to the issue reported.Photograph, video and/or physical sample evaluation: there are photographs associated with this case and in these, the reported defect can be seen.No unused return sample was expected.Conclusion summary of the related event: based on the investigation findings, process observation, tooling analysis and personnel interviews, the investigation concluded that the off center on active life products of convex 1pc is originated due to the following root causes: method: - method for wafer placement onto the cups of the lower level of the rotary table is too general.Due to that a wafer placement variation could be found between the different operators, which can potentially cause a wrong placement of wafers, resulting in a nonconforming product impacted by the off-center defect.- method for pouch placement onto slides plates of the upper level of the rotary table is too general.Due to that a pouch placement variation could be found between the different operators, which can potentially cause a wrong placement of wafers resulting in a nonconforming product impacted by the off-center defect.- not standardized method for the installation of slide plates into the rotary table of convex 1pc.- not standardized method for the installation of cups into the rotary table of convex 1pc.Machine: -worn out guides for slide plates, do not allow guides to properly adjust during the manufacturing process, causing misalignment between pouches and wafers.- incorrect adjustment of cups due to the use of the worn-out screws.- rotation of the glue welding heads causes wafers and pouches decentralization during the assembly process.Opportunity of improvement in the detection method: there is not a visual aid for the off-center defect recognition for active life pouches, in the manufacturing line of convex 1pc.A corrective actions/preventive actions (capa) plan was generated for the mitigate the root causes identified.The investigation associated with related event has been approved and is complete.No additional action is required, and this complaint will be closed.This issue will be monitored through the post market product monitoring review process.To date no additional information has been received.Should additional information become available, a follow-up report will be submitted.Fda registration number reporting site: 1049092 manufacturing site: 9618003.

Event Description

To date no additional patient or event details have been received.

• Brand Name: ACTIVELIFE
• Type of Device: POUCH, COLOSTOMY
• Manufacturer (Section D): CONVATEC DOMINICAN REPUBLIC INC; km 18.5 parque industrial; itabo, s.a. haina; san cristobal
• Manufacturer (Section G): CONVATEC DOMINICAN REPUBLIC INC; km 18.5 parque industrial; itabo, s.a. haina; san cristobal
• Manufacturer Contact: pamela meadows ; 7815 national service road; suite 600; greensboro, NC 27409 ; 3365424679
• MDR Report Key: 10545632
• MDR Text Key: 207297186
• Report Number: 9618003-2020-13846
• Device Sequence Number: 1
• Product Code: EZQ
• UDI-Device Identifier: 00768455181285
• UDI-Public: 00768455181285
• Combination Product (y/n): N
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Consumer
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 08/27/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/17/2020
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Model Number: 175782
• Device Lot Number: 0C02789
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Date Manufacturer Received: 12/01/2023
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 04/14/2020
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Sex: Female