|
Model Number SARP-32 |
Device Problem
Expiration Date Error (2528)
|
Patient Problem
No Known Impact Or Consequence To Patient (2692)
|
Event Date 09/07/2018 |
Event Type
Injury
|
Manufacturer Narrative
|
An event of implantation of an expired product was reported.The 32 mm semi-rigid annuloplasty ring batch number 4783013 expired on august 27, 2018 which was prior to the reported event date of (b)(6) 2018.A review of distribution records confirmed that this product was distributed prior to its expiration date.The device history record was reviewed to ensure that each manufacturing and inspection operation was performed, including verification of the expiration date listed on the product label.The root cause of the reported event is consistent with user error.Additionally, per the instructions for use (ifu) "do not use the ring if the ¿use by¿ date on the packaging has passed.".
|
|
Event Description
|
On (b)(6) 2018, a 32 mm semi-rigid annuloplasty ring (sarp) was selected for a mitral repair after a quadrangular p2 resection.The sarp rings had been scattered on the back table searching for the correct size.The circulator handed the ring to the physician without verifying the expiration date.The physician sutured in the ring and as the procedure was being completed, an operating room staff member identified the device had an expiration date of (b)(6) 2018.The physician elected to leave the device implanted and closed the patient's chest.Post-operatively, the patient was reported to be stable.The patient was notified about the device expiration, and no additional precautions have been taken.The patient has since been discharged on antibiotics.
|
|
Search Alerts/Recalls
|
|
|