The user facility reported that the involved tr band was losing air with withdrawal from syringe.There was no patient injury, medical/surgical intervention required.The patient was stable.The patient's condition was stable.The procedure was a success.Additional information was received on 16oct2020.Prior to the tr band being used, the procedure the patient had was a heart catheterization diagnostic and intervention.The syringe was not sticking inside the valve and there were no difficulties inserting the syringe inside the tr band on-way valve.It was thought that there was a leak in the tr band, they could not pinpoint the location, once the leak was noticed, the removed the tr-band.A hematoma was noticed, and manual pressure was held and controlled, and the patient had a stable outcome.
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This report is being submitted as follow up no.1 to provide the completed investigation results.The actual device was not returned; therefore, an evaluation of the actual device was unable to be conducted.The complaint cannot be confirmed for air leakage since the sample was not returned for evaluation.Based on the information given, the exact root cause of the event cannot be determined.There is no indication that any manufacturing, design or quality system issues may have led to this event.Currently, no action is recommended since this risk evaluation is within the predetermined limits in the fmea.
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