| Catalog Number |
72290126 |
| Medical Device Problem Code |
Delivered as Unsterile Product (1421)
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| Health Effect - Clinical Code |
No Clinical Signs, Symptoms or Conditions (4582)
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| Date of Event |
02/26/2024
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Type of Reportable Event
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Malfunction
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Additional Manufacturer Narrative
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H10: internal complaint reference: (b)(4).
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Event or Problem Description
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It was reported that during a shoulder stabilization, when the box of the 1.8 q-fix disposable kit was opened, it was found that the sharp tip of the drill guide penetrated through the plastic cover, making the kit unsterile and not fit to be used.The procedure was completed using a s+n backup device.There was a delay of less than 30 minutes.No further complications were reported.
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Additional Manufacturer Narrative
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H10 h6: a device deficiency was not identified, and the root cause of the reported event could not be determined since the device was not returned for evaluation.A review of device records showed there were no indications to suggest that the product did not meet manufacturing specifications upon release for distribution.A complaint history review found no similar reported events.A risk management review found that the reported failure and/or harm was documented appropriately, and there were no indications to suggest the anticipated risk is not adequate.Please refer to the instructions for use for precautions and warnings related to the use of the device.No containment or corrective actions are recommended at this time.If the product associated with this event is returned at a future date, this investigation will be reopened for evaluation.
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Additional Manufacturer Narrative
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Internal complaint reference case- (b)(4).H11, h3, h6: the reported device was received for evaluation.A visual inspection revealed it was returned in an original unopened/sealed packaging with the batch number of the complaint on the label.The obturator has penetrated the plastic shipping tray from the inside out, likely during the packaging process.The use of a reference microscope verifies the breach of the sterile barrier.A review of device records showed there were no indications to suggest that the product did not meet manufacturing specifications upon release for distribution.A complaint history review found no similar reported events.A risk management review found that the reported failure and/or harm was documented appropriately, and there were no indications to suggest the anticipated risk is not adequate.A review of the assembly process found that the operator must inspect the trays and tyvek lids before and after the sealing process, looking for blows, cuts, gaps, buckles, embedded particles, among others.A definitive root cause for the reported issue could not be determined.Factors that could have contributed to the failure include procedural variance, or deviations from established protocols, increasing risks and leading to unintended consequences.The investigation findings were escalated to the manufacturing / design team, and it was determined the need for corrective action is not indicated.
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Search Alerts/Recalls
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