MAUDE Adverse Event Report: DEROYAL INDUSTRIES, INC. CMC LAPAROSCOPY PACK; GENERAL SURGERY TRAY (KIT)

Model Number	89-10561
Medical Device Problem Code	Contamination /Decontamination Problem (2895)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/26/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A user facility medwatch report (#4900240000-2021-8110) was received reporting contaminated cmc laparoscopy pack (part 89-10561, lot 54473444).Black specs noted in large basin and on medication labels.Discovered before patient entered the or.New pack obtained.This investigation is ongoing at this time.No further information is available at this time.We will provide follow-up report if additional information becomes available.
Event or Problem Description
Black specs on components (cmc laparoscopy pack).
Additional Manufacturer Narrative
Potential root cause: it was determined, but not limited to, possible employee failure to identify debris, possible dress code violation, lack of lab coat cleanliness, cleaning process not followed or inadequate, exposed product in warehouse, natural occurring static, equipment has loose particulate, inadequate customer satisfaction follow-up, possible inadequate controls identified, possible inadequate assembly methods/instructions, and debris contained in vendor supplied items.The following corrective actions have taken place: manufacturing personnel were retrained on the dress code procedure (corp.Prc.079), quality control specialist started conducting routine walk-throughs in raw material storage areas to identify any potentially exposed product, manufacturing personnel were instructed to wipe down production lines after every order, internal supplier personnel were confirmed to be trained on the cleaning and sanitation procedure, internal supplier performed task training for inspection ensuring that product is free of contamination and debris, supplier corrective action request (scar) was issued to the lab coat supplier, corrective and preventive action point (capa) bp20-21-07-006 has been assigned, and added additional guidance to the manufacturing instructions to indicate that these products have had reports of debris to increase scrutiny during the assembly process.The deroyal sales representative conducted an initial site visit on (b)(6) 2021 in regards to reported complaints of contamination (hair and debris) in procedure trays and collected various defective product samples.The samples were provided in bulk and were not able to be correlated to the corresponding reported quality events.The sales representative performed a follow-up visit on (b)(6) 2021, and the customer agreed to individually bag each separate complaint sample in the future.This investigation is complete at this time.No further information is available at this time.We will provide follow-up report if additional information becomes available.

• Brand Name: CMC LAPAROSCOPY PACK
• Common Device Name: GENERAL SURGERY TRAY (KIT)
• Manufacturer (Section D): DEROYAL INDUSTRIES, INC.; 1501 east central avenue; lafollette TN 37766
• MDR Report Key: 12205004
• Report Number: 3005011024-2021-00003
• Device Sequence Number: 4487298
• Product Code: LRO
• UDI-Device Identifier: 00749756363723
• UDI-Public: 00749756363723
• Combination Product (Y/N): Y
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K842648
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/15/2021

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
• Operator of Device: No Information
• Device Model Number: 89-10561
• Device Catalogue Number: 89-10561
• Device Lot Number: 54473444
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/29/2021
• Initial Date Received by Manufacturer: 06/26/2021
• Supplement Date Received by Manufacturer: 06/26/2021
• Initial Report FDA Received Date: 07/21/2021
• Supplement Report FDA Received Date: 09/15/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1