MAUDE Adverse Event Report: OSCOR INC. SAFESHEATH II; INTRODUCER, CATHETER

Model Number SS7

Device Problems Break (1069); Material Too Rigid or Stiff (1544)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 09/23/2020

Event Type  malfunction  

Manufacturer Narrative

Conclusion not yet available, evaluation in process.A follow-up report will be submitted as soon as the investigation is complete.

Event Description

The issue is that the peel away did not peel in half, needed scissors to cut away the remaining sheath which required a two minute extension.The procedure was completed and no harm was done to the patient.There is a risk of damaging the intracardiac lead when scissors are used to trim away the excess sheath.The device was discarded.

Manufacturer Narrative

H2 correction - in h6 medical device problem code: 1544.Device was used in treatment.The device was not returned for analysis, therefore, the clinical observation cannot be confirmed.The investigation will focus on a review of product documentation.The device history records were reviewed to confirm that the device passed all applicable in-process and final inspections.Per adelante-s introducer sheath in-process and final inspections, ensures sheaths are inspected for visual, dimensional, and peel functional compliance.Destructive testing sampling plan ansi z 1.4, special level 4, aql 0.40 reduced.Step 13.3.2: manually break the sheath and hub and verify that the seals split easily without extreme elongation.Also verify that the split cap and seals remain secure and do not break free or loosen from the sheath hub.A) manually peel the sheath and verify the sheath peels easily along the sheath body and tip.Per adelante, adelante-s and adelante-s2 sheath extrusion step 6.2.3: select the extrusion tooling (pin/die) for the part to be extruded.Prior to installing the tooling, measure and inspect the tooling to ensure its suitability for use.Step 6.3.2: for the two score line model sheath tubes: perform spc charting on the peel strength and critical dimensions.This is to be performed on every 100th extruded sheath.Measure the peel strength of the extruded sheath per procedure.Measure dimensions a-f using the vertex or optical comparator and the laser micrometer for the ovality.Peel test results and dimensional measurements are to be recorded in the extrusion spc data collection sheet.The spc data collection sheet is to be saved under each work order number in the appropriate folder.The information for use (ifu) informs the user: flush sheath with 5cc of saline immediately before peeling sheath away in order to minimize back bleeding.Withdraw sheath and valve over the lead or catheter and from the vessel, while keeping the lead in place.Sharply snap the tabs of valve housing in a plane perpendicular to the long axis of the sheath to split the valve and peel sheath apart while withdrawing from the vessel.No further follow-up is required.Based on the investigation, a capa is not required as findings did not identify a design, labeling or manufacturing non-conformity.In addition, there was no new failure mode identified and the risk remains acceptable.The event will be re-evaluated if additional information becomes available.Oscor will continue to monitor this event type and risk.Oscor inc.Is submitting the above report to comply with 21 cfr part 803, the medical device reporting regulation.The report is based upon information obtained by oscor inc.Which the company may not have been able to investigate or verify prior to the date the report was required by fda.This report does not constitute an admission that the device, oscor inc., or its employees, caused or contributed to the event described in this report.Nor does this report reflect a conclusion by fda, oscor inc., or its employees, that the report constitutes an admission that the device, oscor inc., or its employees caused or contributed to the event described in this report.

Manufacturer Narrative

Corrected h4: device manufacture date is 06-mar-2020.Oscor inc.Is submitting the above report to comply with 21 cfr part 803, the medical device reporting regulation.The report is based upon information obtained by oscor inc.Which the company may not have been able to investigate or verify prior to the date the report was required by fda.This report does not constitute an admission that the device, oscor inc., or its employees, caused or contributed to the event described in this report.Nor does this report reflect a conclusion by fda, oscor inc., or its employees, that the report constitutes an admission that the device, oscor inc., or its employees caused or contributed to the event described in this report.

• Brand Name: SAFESHEATH II
• Type of Device: INTRODUCER, CATHETER
• Manufacturer (Section D): OSCOR INC.; 3816 desoto blvd.; palm harbor FL 34683
• MDR Report Key: 10743221
• MDR Text Key: 225929630
• Report Number: 1035166-2020-00066
• Device Sequence Number: 1
• Product Code: DYB
• UDI-Device Identifier: 30891492002228
• UDI-Public: 30891492002228
• Combination Product (y/n): N
• PMA/PMN Number: K122084
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor,foreign,health pr
• Type of Report: Initial,Followup,Followup
• Report Date: 01/20/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/27/2020
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: SS7
• Device Catalogue Number: SS7
• Device Lot Number: DP11590
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 01/18/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1