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(b)(6).Method: the subject ojr416 optiflow junior 2 nasal cannula was not returned to fisher & paykel healthcare (f&p) for evaluation as it was discarded following the reported event.Our investigation is based on the information, photograph and description of events provided by the distributor, previous investigations of similar complaints and our knowledge of the product.Results: visual inspection of the provided photograph revealed that the tubing of the ojr416 optiflow junior 2 nasal cannula was found detached from the cannula, confirming the reported fault.The detached end of the tube was also observed to be stretched.Conclusion: our investigation was unable to determine the exact cause of the observed damage to the ojr416 optiflow junior 2 nasal cannula.Based on our knowledge of the product the tubing was likely subjected to excessive force.The optiflow junior nasal cannula is designed specifically for the delicate anatomical features and flow requirements of neonatal and pediatric patients.It features adhesive pads (wigglepads) to maintain cannula stability on the patient's cheeks, soft-touch nasal prongs and breathable kink-proof and crush-resistant flexible tubing.All optiflow junior cannula are 100% leak and occlusion tested after final assembly and any cannula that fails is discarded.In addition, samples are taken hourly from each run and pull tested to check glue joint strength at the cannula tube joint, as well as the swivel grip joint, if there are any failures the entire batch is put aside for further investigation.The subject ojr416 optiflow junior 2 nasal cannula would have met the required specifications at the time of production.The user instructions which accompany the ojr416 optiflow junior 2 nasal cannula show in pictorial format the correct placement and fitting of the cannula, and provide the following warnings: - "appropriate patient monitoring (e.G., oxygen saturation) must be used at all times.Failure to monitor the patient may result in loss of therapy, serious harm or death." - "ensure all connections are secure during use.Check the cannula is undamaged and that the flow path is maintained.Under excessive load, the cannula may disconnect to prevent forces being transferred to the patient." - "do not stretch the cannula on application; this may cause increase pressure to the patient's skin.If necessary, the cannula may be repositioned.".
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