You should already be well aware that deficiencies in complaint handling and Medical Device Reporting are two of the most common reasons why the FDA issues 483 inspection observations and Warning Letters (http://bit.ly/FY2013-483-Data-Analysis). Recently, I posted a blog about “Where to Focus your Medical Device Complaint Handling Training” (http://bit.ly/Complaint-Training). The following is a summary of my responses to reader questions.
What criteria do you think should be used to determine whether a complaint should be investigated or not?
There is only one acceptable rationale for not conducting an investigation of a complaint. If you don’t investigate complaints when required, then you might receive an FDA Form 483 observation worded like this…
21 CFR 820.198(c) – Complaints involving possible failure of labeling to meet any of its specifications were not investigated where necessary. Specifically, a missing IFU was reported in customer complaints, but no investigation was conducted. The rationale documented in the complaint record was “the missing IFU presented no patient risk.”
A missing IFU is “failure of labeling to meet any of its specifications.” Therefore, 21 CFR 820.198(c) requires you to conduct an investigation “unless such investigation has already been performed for a similar complaint and another investigation is not necessary.” This is the only rationale that is acceptable for skipping your investigation. To ensure that no one forgets to investigate a complaint, make sure you include a space in your complaint handling form that is specifically labeled as “Summary of Complaint Investigation.” This space should also include an option to cross-reference to a previous complaint record where a similar investigation is already documented.
A missing IFU is also considered misbranded product that requires correction (e.g., sending the customer a replacement IFU) or removal (i.e., recall). The FDA expects a Health and Hazard Evaluation (HHE) form to be included in your recall records (http://bit.ly/HHE-Form), and the HHE should indicate the potential risk of a “delay in treatment.” This is the FDA’s conclusion in their evaluation of risk and therefore your HHE must identify a delay in treatment is a patient risk too. The FDA also expects a CAPA to be initiated to prevent recurrence of this type of labeling error. You can make a “risk-based” determination that reporting a specific recall to the FDA is not required as per 21 CFR 806.20. However, you need to maintain records of your determination not to report a recall. If you already received a Warning Letter, you should err on the side of reporting anyway.
Note: References to “recall” in the above paragraph are meant to include field corrections.
If a complaint consists of a medical device being used for something other than its intended use, is an MDR required for this user error?
The answer is yes. If you don’t report adverse events involving “user error,” then you might receive an FDA Form 483 observation worded like this…
21 CFR 803.17(a)(1) – The written MDR procedure does not include an internal system which provides for the timely and effective evaluation of events that may be subject to medical device reporting requirements. Specifically, several incidents where a death or serious injury occurred were “caused by a user error,” and the procedure did not identify this as an event requiring Medical Device Reporting.
In 21 CFR 803.3 (http://bit.ly/21CFR803-3), the FDA defines “caused or contributed” to include events occurring as a result of:
- Improper or inadequate design
- Labeling, or
- User error
It is important to understand that the definition of complaints and the requirement to report adverse events should not be “risk-based.” The need for remediation and the need to report corrections and removals can be “risk-based,” but whether something is a complaint, and whether it is reportable should be “black-and-white.” For example, “Did the death or serious injury occur due to a ‘user error’–including use other than the intended use?” If the answer is yes, then it is a complaint and reportable.
Do incidents that occurred outside the United States need to be reported to FDA?
The answer is yes. If you don’t report adverse events that occur outside the United States, then you might receive an FDA Form 483 observation worded like this…
21 CFR 820.50(a)(1) – An MDR report was not submitted within 30 days of receiving or otherwise becoming aware of information that reasonably suggests that a marketed device may have caused, or contributed to, a death or serious injury. Specifically, several instances were identified where the device caused, or contributed to, a death or serious injury, and the event was not reported to the Agency. The rationale documented in the complaint record was that the “event occurred outside the United States.”
This type of mistake is most likely due to a lack of training on 21 CFR 803–Medical Device Reporting. Some manufacturers that distribute product internationally are more familiar with the European Vigilance requirements (http://bit.ly/MEDDEV2-12-1rev8). The European Medical Device guidelines clearly indicate in the scope section that “the guidelines are relevant to incidents occurring within the Member States of the European Economic Area (EEA), Switzerland, and Turkey…”. Therefore, standard industry practice is to not report these events, unless the events occurred in Europe.
The FDA Part 803 requirements are worded differently. Part 803 does not indicate that the event had to occur in the United States. By not stating that MDR’s are to be filed for events in the United States only, it is the FDA’s expectation that manufacturers shall report events occurring outside the U.S. if the devices are “similar” to devices marketed in the U.S. Unfortunately, the FDA’s expectations have not become “Standard Practice” for all manufacturers. Therefore, the FDA is currently circulating a new guidance in draft form to clarify this requirement (http://bit.ly/2013-MDR-Draft-Guidance).
If you need help with training on complaint handling or Medical Device Reporting, please download our free webinar: (http://bit.ly/chvg_mda).