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

Model Number	SS7
Medical Device Problem Code	Material Too Rigid or Stiff (1544)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/27/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Conclusion not yet available, evaluation in process.A follow-up will be submitted as soon as the investigation is complete.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.
Event or Problem Description
No event details providing what broke on the sheath or what the physician had to cut on the sheath in order to remove the sheath.No patient symptoms or complications associated with this event were reported.No additional event information provided concerning any delay in the procedure.No additional event information provided concerning a medical or surgical intervention.No pictures or video are available.The device will be returned for evaluation.
Additional Manufacturer Narrative
Additional information: g2 reported source - foreign.Two 7f safesheath ii introducer sheaths were returned without dilators from the customer and there were no other accessories.There was blood on both sheaths.According to the event description summary, the sheaths "broke" upon "slitting" and had to be cut in order to remove them.Sheath #1: upon receipt of the product, the sheath was already partially peeled apart (including the hub) and the hemostatic valve did not break in half as intended.The hemostatic valve broke/tore at the peg holes that hold the valve in place under the hub and caused it to slip out from under the hubcap.This occurred because valve was not sufficiently cut with the partial cut required to break the hemostatic valve in half.Since the valve wasn't sufficiently cut, it allowed the outer part of the valve to break and slip out from under the hub/hubcap assembly when the sheath was peeled apart by the end user.Sheath #2: upon receipt of the product, the sheath was already partially peeled apart (including the hub) and the hemostatic valve broke in half but was stretched out and looked like it took some force to break in half; the valve broke apart a bit unevenly, but the peg holes are intact.Per manufacturing procedure introducer set, silicone seal slitting: once the cutting cycle is complete, the part will be placed on the machine tray.Remove the seal from the tray and perform a visual inspection using a 10x microscope.Finished center helix cut - verify the helix cut is complete and the seal was severed completely by checking for helix cut on the top and bottom of seal.Additional inspection for split seals: if the work order is for split seals prior to providing qa with the 5 samples, visually inspect and pull test the first 3 seals per seal pull test.If the pull tests are within specification, continue to run the first 5 samples for qa acceptance, visually inspect and submit to qa.Production may continue and seals may continue to be manufactured while pending the completion of the qa inspection.Partial cut - if the seal has a partial cut, ensure the cut did not cut through the full width of the seal (blade did not sever the membrane).Per qa procedure adelante s2s introducer sheath in-process and final inspection destructive testing.Sampling plan ansi z 1.4, special level 4, aql 0.40 reduced.Break and peel test: using samples from fit check, manually break the sheath and hub and verify that the seal splits easily without extreme elongation.Also verify that the split cap and seal remain secure and do not break free or loosen from the sheath hub.The instructions 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.Returned device analysis revealed hemostatic valve of sheath #1 did not break apart during use.The valve was not cut sufficiently enough to tear in half as intended.The valve of sheath #2 broke in half and peeled along the score line as intended.Manufacturing and qa personnel have been notified of this issue to raise awareness and were informed to pay close attention to this detail.According to the device history record, the introducer sheaths passed all in-process and qa final inspection steps before shipping to the customer including visual, dimensional and mechanical testing.In conclusion, based on the information available at this time it is confirmed that the product failed to meet requirements.A corrective action was opened to investigate the root cause and implement corrective action to prevent recurrence of this issue.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.

• Brand Name: SAFESHEATH II INTRODUCER
• Common Device Name: INTRODUCER, CATHETER
• Manufacturer (Section D): OSCOR INC.; 3816 desoto blvd.; palm harbor FL 34683
• Manufacturer (Section G): OSCOR INC.; 3816 desoto blvd.; palm harbor FL 34683
• Manufacturer Contact: daniel naut ; 3816 desoto blvd.; palm harbor, FL 34683 ; 7279372511
• MDR Report Key: 18682725
• Report Number: 1035166-2024-00010
• Device Sequence Number: 7396115
• Product Code: DYB
• UDI-Device Identifier: 30891492002228
• UDI-Public: 30891492002228
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K122084
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 04/09/2024

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: Health Professional
• Device Model Number: SS7
• Device Catalogue Number: SS7
• Device Lot Number: DP20035
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/29/2024
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/17/2024
• Supplement Date Received by Manufacturer: 03/15/2024
• Initial Report FDA Received Date: 02/10/2024
• Supplement Report FDA Received Date: 04/09/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 08/21/2023
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown