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Recall Observatory FDA recall evidence

Device product

Custom procedural convenience kits and trays, general & plastic surgery, labeled as: a) BRACHY THERAPY PROCEDURE PAC, kit number AGBR90E; b) BRACHY THERAPY PROCEDURE PAC, kit number AGBR90E; c) MINI MINOR AGH ASC PACK, kit number AGMM60M; d) OUTPATIENT PORT ACCESS KIT 307907, kit number AHPO55J; e) General Pack, kit number BBGP31C; f) FRACTURE TABLE PACK, kit number FDFT75N; g) Arthroscopy Pack, kit number HCAR04K; h) BARIATRIC PACK, kit number HGBA92F; i) LAPAROTOMY PACK, kit number HNLP12J; j) MIDLINE CHANGE KIT, kit number HSMD20E; k) Minor General, kit number JSMI10I; l) ENDO VASCULAR PACK, kit number LVEV61; m) MAJOR PACK, kit number LVMJ21; n) HEAD AND NECK PACK, kit number MMHN37F; o) KIT, MINOR U BAR, kit number MMNU34E; p) KIT, MAJOR UNIVERSAL, kit number MMUN28E; q) VAG PLASTY PACK, kit number OSVP16; r) DR L MAJOR, kit number SALM40H; s) DR L MAJOR, kit number SALM40I; t) MINOR BASIN SAH, kit number SAMB25E; u) MAJOR SAH, kit number SAMJ36G; v) MINOR PACK, kit number SMMN65; w) General Pack, kit number THGN59D; x) MINOR PACK, kit number TPMN15; y) MAJOR UNIVERSAL PACK, kit number TPUN48

Z-0825-2024

November 29, 2023

Class II

Product summary

Firm
American Contract Systems, Inc.
Event
Event 93656
Status
Ongoing
Classification
Class II
Quantity
7881 units
Official record key
device-enforcement:Z-0825-2024

Official wording

Reason: During an internal investigation, ACS identified that several components were "piggybacked" to ACS trays and subjected to the ACS sterilization process. There is no supporting documentation stating the "piggybacked" components were assessed to determine if they were suitable for exposure to elevated temperatures for an extended period of time and further exposure to sterilization. As a result, the piggybacked components may (1) have a loss/lack of functionality, (2) loss of drug efficacy, if applicable, and (3) may have had higher than specified EO residuals.

Code information: a) AGBR90E, UDI/DI 00191072036865, Lot Numbers: 959231, exp. 02/10/2024; 681221, exp. 11/15/2023; 721221, exp. 09/30/2023; 771221, exp. 08/147/2023; 827221, exp. 06/22/2023; 897221, exp. 04/13/2023; b) AGMM60M, UDI/DI 00191072063786, Lot Numbers: 939231, exp. 03/02/2024; 638221, exp. 4528812/28/2023; 694221, exp. 11/02/2023; 734221, exp. 09/23/2023; 769221, exp. 08/19/2023; c) AHPO55J, UDI/DI 00191072171566, Lot Numbers: 682221, exp. 11/14/2023; 661221, exp. 12/5/2023; 977231, exp. 1/23/2024; 945231, exp. 2/24/2024; 891231, exp. 4/19/2024; d) BBGP31C, UDI/DI none, Lot Numbers: 687221, exp. 11/9/2023; 738221, exp. 9/19/2023; 805221, exp. 7/14/2023; 870221, exp. 5/10/2023; e) FDFT75N, UDI/DI none, Lot Numbers: 773221, exp. 8/15/2023; 714221, exp. 10/13/2023; 990231, exp. 1/10/2024; 935231, exp. 3/6/2024; 890231, exp. 4/20/2024; 870231, exp. 5/10/2024; f) HCAR04K, UDI/DI 00191072114174, Lot Numbers: 757221, exp. 08/31/2023; g) HGBA92F, UDI/DI none, Lot Numbers: 757221, exp. 8/31/2023; 695221, exp. 11/1/2023; 635221, exp. 12/31/2023; h) HNLP12J, UDI/DI 00191072146274, Lot Numbers: 805221, exp. 7/14/2023; 742221, exp. 9/15/2023; 673221, exp. 11/23/2023; 924231, exp. 3/17/2024; i) HSMD20E, UDI/DI 00191072130068, Lot Numbers: 898221, exp. 4/12/2023; 772221, exp. 8/16/2023; 984231, exp. 1/16/2024; j) JSMI10I, UDI/DI none, Lot Numbers: 766221, exp. 08/22/2023; k) LVEV61, UDI/DI 00191072033475, Lot Numbers: 678221, exp. 11/18/2023; 637221, exp. 12/29/2023; l) LVMJ21, UDI/DI 00191072139023, Lot Numbers: 833221, exp. 6/16/2023; 764221, exp. 8/24/2023; 717221, exp. 10/10/2023; 988231, exp. 1/12/2024; 954231, exp. 2/15/2024; m) MMHN37F, UDI/DI none, Lot Numbers: 639221, exp. 12/27/2023; n) MMNU34E, UDI/DI none, Lot Numbers: 928231, exp. 3/13/2024; 889231, exp. 4/21/2024; o) MMUN28E, UDI/DI none, Lot Numbers: 889231, exp. 04/21/2024; p) OSVP16, UDI/DI 00191072156570, Lot Numbers: 827221, exp. 6/17/2023; q) OSVP16, UDI/DI 00191072170835, Lot Numbers: 700221, exp. 10/23/2023; 644221, exp. 12/4/2023; 987231, exp. 11/20/2023; r) SALM40H, UDI/DI none, Lot Numbers: 826221, exp. 6/23/2023; 888221, exp. 4/22/2023; s) SALM40I, UDI/DI none, Lot Numbers: 687221, exp. 11/9/2023; 756221, exp. 9/1/2023; 984231, exp. 1/16/2024; t) SAMB25E, UDI/DI none, Lot Numbers: 843221, exp. 6/6/2023; 894221, exp. 4/16/2023; 871221, exp. 5/9/2023; 686221, exp. 11/10/2023; 758221, exp. 8/30/2023; 793221, exp. 7/26/2023; 974231, exp. 1/26/2024; u) SAMJ36G, UDI/DI none, Lot Numbers: 660221, exp. 12/6/2023; 704221, exp. 10/23/2023; 752221, exp. 9/5/2023; 800221, exp. 7/19/2023; v) SMMN65, UDI/DI 00191072188472, Lot Numbers: 969231, exp. 1/31/2024; 926231, exp. 3/15/2024; w) SMMN65, UDI/DI none, Lot Numbers: 919231, exp. 3/22/2024; x) THGN59D, UDI/DI 00191072191069, Lot Numbers: 805221, exp. 7/14/2023; 721221, exp. 10/6/2023; y) TPMN15, UDI/DI 00191072171771, Lot Numbers: 737221, exp. 9/20/2023; 702221, exp. 10/25/2023; 664221, exp. 12/2/2023; 990231, exp. 1/10/2024; 960231, exp. 2/9/2024; 939231, exp. 3/2/2024; 903231, exp. 4/7/2024; z) TPUN48, UDI/DI 00191072171832, Lot Numbers: 738221, exp. 9/19/2023; 688221, exp. 11/8/2023; 637221, exp. 12/29/2023; 967231, exp. 2/2/2024; 924231, exp. 3/17/2024

Distribution pattern: US Nationwide distribution.

Derived failure modes

  • Unknown

    reason.no_named_rule · v1.0.0

    During an internal investigation, ACS identified that several components were "piggybacked" to ACS trays and subjected to the ACS sterilization process. There is no supporting documentation stating the "piggybacked" components were assessed to determine if they were suitable for exposure to elevated temperatures for an extended period of time and further exposure to sterilization. As a result, the piggybacked components may (1) have a loss/lack of functionality, (2) loss of drug efficacy, if applicable, and (3) may have had higher than specified EO residuals.