H.6.Investigation summary: customer returned seven (6) 29gx12.7mm, 0.5ml bd insulin syringes from an opened polybag from lot 8239936.Consumer reported when opening the polybag, a nurse got needle stick injury due to cannula through shield.All seven returned syringes were examined and it was observed that one syringe exhibited a cannula through shield.The other six syringes did not exhibit a cannula through shield.A review of the device history record was completed for batch# 8239936.All inspections and challenges were performed per the applicable operations qc specifications.There were zero (0) notifications noted that pertained to the complaint.Investigation conclusion: bd was able to duplicate or confirm the customer¿s indicated failure.Complaints received for this device and reported condition will continue to be tracked and trended.Information will be captured on trend reports and monitored monthly.Our business team regularly reviews the collected data for identification of emerging trends.Root cause description: after visual inspection of the physical sample , we would confirm that it is bent and hooked cannula and happened after getting cannulated, passed the pim inspection for cannula angularity.It must have happened during the process of shielding.Process: racks loaded with hubs travel down a conveyor towards the cannulator.They approach the cannulator turning horizontally in order to receive cannula.Racks pass under mars magnet straightening the cannula in the hubs.The rack passes under two ultraviolet lamps, which causes the adhesive to cure.Then the racks go to the shielder with the use of linear motion.The rack locater positions the racks while getting shielded.The parts are first inspected with an angularity camera, and if the angle of the cannula is too great or there is nothing on that pin, the part is not shielded.The finished product pick and place head won¿t pick it up in the gripper as it is gripping the shield for pick up.Investigation: did not find any l2l dispatches for repairs/ adjustments.There were no notifications pertaining to the complaint.Root cause: root cause cannot be determined as there were no changes to the process, also did not find any repairs and adjustments.Complaints received for this device and reported condition will continue to be tracked and trended.Information will be captured on trend reports and monitored.Our business team regularly reviews the collected data for identification of emerging trends." rationale: based on the investigation, no additional investigation and no capa is required at this time.
|