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It was reported that the nurses had a hard time trying to get suction through the drain into the canister at the end of a spine case.The complainant reported that upon inspection, they found that the drain had clear scotch tape wrapped around it, which covered up a very obvious tear in the drain.The complainant noted that the device came in the package in that condition.The drain was reportedly replaced.
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It was reported that the nurses had a hard time trying to get suction through the drain into the canister at the end of a spine case.The complainant reported that upon inspection, they found that the drain had clear scotch tape wrapped around it, which covered up a very obvious tear in the drain.The complainant noted that the device came in the package in that condition.The drain was reportedly replaced.
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The reported event was confirmed.Visual evaluation of the returned sample noted one opened (with original packaging), used (note biological detritus throughout) portion of a drain tube.Visual inspection of the sample noted apparent scotch tape around a break in the drain tubing.The break was jagged and uneven.This was out of specification, which states "no damaged or missing components." although the reported event was confirmed, the root cause could not be determined.A potential root cause for this failure could be, ¿drain was manufactured incorrectly (dimensions or material out spec, curing time not appropriate, etc.).¿ the device history record was reviewed and found nothing that could have caused or contributed to the reported event.The instructions for use were found adequate and state the following: ¿vii.Instructions for use: 1.The surgeon should irrigate the wound with sterile fluid and then suction the irrigating fluid and gross debris from the operative site.2.Tubes should lie flat and in line with the anticipated skin exit.To facilitate later removal by manual traction, the tubing should not be curled, pinched, or sutured internally.3.Positioning of the drain in the body cavity, as well as the number of drains indicated, should be determined by the surgeon.4.Drain tubing should be placed within the wound by approximating the areas of critical fluid collection.5.Care must be taken to ensure that all drain perforations or channels lie completely within the wound or cavity to be drained.6.Taping or a triple loop suture (around and not through the tubing) will aid in preventingaccidental drain placement.7.Deep drainage is best accomplished by using one or more drains for each level of tissue.Each level should be evacuated by a separate vacuum source.8.Care must be exercised to avoid damage to the drain (refer to warnings).The tubing should be repeatedly checked during closure for free motion to avoid breakage and/or fragment retention within the wound.9.When using a trocar please follow these instructions: 9.I.) with one drain: - draw drain using trocar from inside to outside of wound.- ensure that perforated section of the drain is within the critical fluid collection areas of wound.- remove trocar only by cutting the drain one inch from the end of the trocar.- trim non-perforated section of drain to desired length.- attach non-perforated section of drain either to an evacuator inlet port or to a y-connector.9.Ii.) with two single drains: - follow instruction #9.I for each of the two drains separately.9.Iii.) with a double drain: - draw drain using trocar from inside to outside of wound.- ensure that desired perforated region of the drain is within the critical fluid collection areas of wound.- cut the outer portion of the drain (outside the wound area) in the middle of the perforated region.Attach non-perforated section of the inserted drain to an evacuator inlet port or to a y-connector.- after cutting (as mentioned above), the second half of this drain can be used separately.If you are not using the second half then dispose of it as per the hospital protocol.10.Attach drain to evacuator tubing via the y-connector.11.Insert free end of evacuator y-tubing into evacuator suction port a.12.Fully compress evacuator by hand and close drain port b.Unit is now operational.13.To empty unit, clamp y-tubing.Open drain port b.Hold unit with open port at bottom and compress until fluid is removed.14.For continued wound evacuation compress unit fully and close drain port b.Release clamp on y-tubing." h11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.
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