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Summary of event: it was reported that during inspection of products at an international distribution center, foreign matter was found in the packaging of six roadrunner the firm lt hydrophilic wire guide's.There was no patient involvement.Investigation evaluation: reviews of the complaint history, device history record (dhr), instructions for use (ifu), and quality control procedures were conducted during the investigation.A visual inspection of the complaint devices and customer provided photos were also conducted.The customer returned six devices to cook for investigation.Foreign matter was found in five of the six devices.A document-based investigation evaluation was performed.A review of the device history record found that nine devices from the complaint lot did not pass quality control inspections; however, the affected products were scrapped or reworked prior to release from cook.A review of complaint history found no additional related complaints for the complainant lot.The product ifu states, ¿supplied sterilized by ethylene oxide gas in peel-open packages.Intended for one-time use.Sterile if package is unopened and undamaged.Do not use the product if there is doubt as to whether the product is sterile.Store in a dark, dry, cool place.Avoid extended exposure to light.Upon removal from package, inspect the product to ensure no damage has occurred.¿ a review of the device master record (dmr) concluded that sufficient inspection activities are in place to identify this failure mode prior to distribution.The information provided upon review of the returned devices, customer provided photos, complaint file, ifu, dmr, and dhr suggests that there is evidence that the device was manufactured out of specification.However, cook has concluded that this issue is an isolated incident, and there is no evidence of additional nonconforming devices in house or out in the field.Although nine devices from the complaint lot did not pass quality control inspections, the products were scrapped or reworked prior to release from cook, there are 100% inspections in place, adequate inspection activities have been established, there is objective evidence that the dhr was fully executed, and no other lot-related complaints have been received from the field.Therefore, it was concluded that there is no evidence that devices manufactured out-of-specification exist in-house or in the field.Based on the information provided and the results of the investigation, cook has concluded manufacturing and quality control deficiencies contributed to this incident.The risk analysis for this failure mode was reviewed, and no additional escalation was required.The appropriate personnel have been notified, and cook will continue to monitor for similar events.This report is required by the fda under 21 cfr part 803 and is based on unconfirmed information submitted by others.Neither the submission of this report nor any statement contained herein is intended to be an admission that any cook device is defective or malfunctioned, that a death or serious injury occurred, nor that any cook device caused, contributed to, or is likely to cause or contribute to a death or serious injury if a malfunction occurred.
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