MAUDE Adverse Event Report: DEROYAL INDUSTRIES, INC. KNEE PACK; GENERAL SURGERY TRAY

Model Number 89-9810

Device Problems Material Puncture/Hole (1504); Material Perforation (2205); Material Integrity Problem (2978)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 02/26/2019

Event Type  malfunction  

Manufacturer Narrative

Investigation summary: an internal complaint (call (b)(6)) was received indicating that a convenience kit (finished good 89-9810, lot 48283775) contained a defective light handle cover.The end user reported the light handle cover contained a hole that was not discovered until after the procedure was completed, resulting in contamination to the sterile field.A sample was initially reported to be available.However, as of the date of this report, that sample has not been received.The work order for the reported finished good lot was reviewed for possible discrepancies that may have contributed to the event.No discrepancies were identified.The bill of materials for the kit was reviewed and raw material 755059 was identified as the light handle cover referenced in the complaint report.This raw material is supplied to deroyal by (b)(4).The 2017-2019 supplier corrective action request (scar) and supplier notification letter logs were reviewed for similar complaints.Similar complaints have been identified, and a scar was issued to (b)(4).As of the date of this report, a response has not been received.The investigation is ongoing at this time.When new and critical information is received, this report will be updated.

Event Description

There was a large hole in a light handle cover that was not discovered until after the procedure was completed, thus contaminating the sterile field.The light handle cover was packaged in a convenience kit.

Event Description

There was a large hole in a light handle cover that was not discovered until after the procedure was completed, thus contaminating the sterile field.The light handle cover was packaged in a convenience kit.

Manufacturer Narrative

Root cause: the affected kit component is supplied to deroyal by steris corporation.Therefore, a supplier corrective action request (scar) was issued to steris.In its response, steris report the true root cause is unknown.The supplier completed an evaluation of its processes, material, and equipment, and no symptoms existed to indicate potential to create holes in light handle covers.It is possible there may have been an intermittent temporary variation in the forming process, but monitoring results have not revealed evidence to confirm that.Corrective action: the supplier reported the following corrective actions: product tooling maintained and cleaned, checks occurring three times per shift to verify compliance, and hourly line checks to verify compliance.Investigation summary an internal complaint (call 46470) was received indicating that a convenience kit (finished good 89-9810, lot 48283775) contained a defective light handle cover.The end user reported the light handle cover contained a hole that was not discovered until after the procedure was completed, resulting in contamination to the sterile field.A sample was initially reported to be available.A sample was returned march 22, 2019, to deroyal.This sample contained a hole, confirming the reported issue.The work order for the reported finished good lot was reviewed for possible discrepancies that may have contributed to the event.No discrepancies were identified.The bill of materials for the kit was reviewed and raw material 755059 was identified as the light handle cover referenced in the complaint report.This raw material is supplied to deroyal by steris corporation.The 2017-2019 supplier corrective action request (scar) and supplier notification letter logs were reviewed for similar complaints.Similar complaints have been identified, and a scar was issued to steris corporation.A response was received and accepted may 21, 2019 by deroyal personnel.The investigation is complete at this time.If new and critical information is received, this report will be updated.

• Brand Name: KNEE PACK
• Type of Device: GENERAL SURGERY TRAY
• Manufacturer (Section D): DEROYAL INDUSTRIES, INC.; 1501 east central avenue; lafollette TN 37766
• MDR Report Key: 8460067
• MDR Text Key: 144988782
• Report Number: 3005011024-2019-00003
• Device Sequence Number: 1
• Product Code: LRO
• UDI-Device Identifier: 00749756945448
• UDI-Public: 00749756945448
• Combination Product (y/n): N
• PMA/PMN Number: K842648
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: user facility
• Type of Report: Initial,Followup
• Report Date: 06/07/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 89-9810
• Device Lot Number: 48283775
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/22/2019
• Initial Date Manufacturer Received: 02/26/2019
• Initial Date FDA Received: 03/28/2019
• Supplement Dates Manufacturer Received: 02/26/2019
• Supplement Dates FDA Received: 06/14/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1