|
On (b)(6) 2025, the patient exhibited elevated blood pressure.During invasive blood pressure catheterization, the steel needle was not withdrawn prior to the procedure, resulting in a lateral crack in the catheter after insertion.The puncture site and invasive catheter were replaced, and the procedure was repeated.Re-puncture.
|
|
Investigation results: in addition to the fact that no records were found that could explain this complaint during the analysis of the batch history, nonconformities, and corrective maintenance, this complaint does not include samples or photos for analysis, making it impossible to confirm.According to the complaint description: ¿during venous catheterization for blood pressure measurement, the steel needle was not removed before the procedure, resulting in a lateral crack in the catheter after insertion.¿ based on the investigation carried out so far, a possible cause of the complaint may be related to: product usability: as described in the complaint, the deviation occurred during use.The catheter may have been pushed forward, and during recannulation, trans fixation of the catheter may have occurred.Product assembly: there may have been an isolated failure in the vision system, allowing a trans fixated catheter to pass to the customer.However, if the catheter had been trans fixated before puncture, its use would not have been possible.
|