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

Model Number	89-10558
Medical Device Problem Code	Contamination /Decontamination Problem (2895)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/13/2023
Type of Reportable Event	Malfunction
Event or Problem Description
Hair on light handle cover packaging.
Additional Manufacturer Narrative
A complaint was received on 1/1252024 reporting hair found on light handle cover packaging.The sample was returned for evaluation, hair/debris was found on the outside of package.The root cause for this event was determined to be: assemblers failed to do a visual inspection of the light handle cover package.Per personnel dress code procedure corp.Prc.079, a mirror is placed in areas to allow employees to ensure that bouffant, beard covers and/or lab coats are applied appropriately.Personnel entering the clean manufacturing area shall perform the following steps prior to entering the room.Apply hair coverings, then next apply apparel, then if applicable apply shoe covers.Last step, wash or sanitize hands.Bouffant must cover all of hair.In order to contain all hair, more than one covering may be needed.Once a hair covering is removed, it must be discarded.Reapplication of the hair cover and beard/mustache cover must be with a new cover.Bouffant may not be worn outside of building.Brushing or combing of hair is not allowed in the changing room or any other area where products are handled or stored.Beard and/or mustache covers shall be worn in all areas that a bouffant hair covering is required and should cover all facial hair.Once removed, it must be discarded.Reapplication must be with a new cover.Lab coats are required in all clean manufacturing areas.Apparel / lab coats shall be buttoned/snapped.Apparel / lab coats shall be kept completely closed.Apparel / lab coats are not to be worn outside of the manufacturing area by manufacturing personnel.Per cleaning, sanitation and work environment procedure corp.Prc.086, machine operators shall ensure the work surface of each machine is free from dust, dirt, oil, debris and/or other foreign matter.All equipment used in production shall be cleaned.Garbage shall be removed daily as required by the respective cleaning checklist or form (do not transfer trash from one container to another).Daily - clean work area, work tables, manufacturing equipment, countertops and tables, empty trash, sweep floors and fatigue mats.The following corrective and or preventive actions have taken place by deroyal: all employees responsible for building this tray have been retrained on acd.Qlp.034 workorder process, to ensure they do a visual inspection of components before placing into the tray.Production records were reviewed, and no issues were found.An inventory check of the light handle cover was made by deroyal, a total of 25 of the 869734 were inspected, no discrepancies were identified during the inspection and no debris/hair was found on the component ot package.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: CCASC LAPAROTOMY PACK
• Common Device Name: GENERAL SURGERY TRAY (KIT)
• Manufacturer (Section D): DEROYAL INDUSTRIES, INC.; 1501 east central avenue; lafollette TN 37766
• Manufacturer (Section G): DEROYAL INDUSTRIES, INC.; 1501 east central avenue; lafollette TN 37766
• Manufacturer Contact: rose earl ; 200 debusk lane; powell, TN 37849 ; 8653621051
• MDR Report Key: 18687573
• Report Number: 3005011024-2024-00005
• Device Sequence Number: 20395634
• Product Code: LRO
• UDI-Device Identifier: 00749756364430
• UDI-Public: 00749756364430
• Combination Product (Y/N): N
• 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): N
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 02/12/2024

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
• Device Model Number: 89-10558
• Device Lot Number: 59961228
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/25/2024
• Initial Report FDA Received Date: 02/12/2024
• 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