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The device history record was reviewed and confirmed the lot subject of the event was manufactured to specifications.A complaint review was performed and confirmed the reported event to be isolated.The reported event may be attributed to the cap for the biological indicator being loose before it was placed in the incubator.The cap should be tightened after the biological indicator is activated (crushed).Through follow-up, it was stated that user facility personnel utilized a vial crusher to activate the biological indicator; however, the vial crusher is not a steris product and may be incompatible with the self-contained biological indicator subject of the reported event.Steris is the contract manufacturer of the device subject of the event and does not have the user facility contact information.Steris notified the manufacturer, true indicating llc, to provide the investigation results and perform retraining with the user facility.No additional issues have been reported.
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